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1
Sharma, Kamal, August Stuart, Elliot M. Epner, and Thomas P. Loughran. "Overcoming Ibrutinib Resitance In Relapsed Chronic Lymphocytic Leukemia." Blood 122, no. 21 (2013): 4891. http://dx.doi.org/10.1182/blood.v122.21.4891.4891.
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Abstract Resistance to ibrutinib (PCI-32765) is uncommon and not well described. Here we describe a 78 year old Caucasian man with a long standing history of CLL originally diagnosed in 2004. He was treated at the James Cancer Hospital and Fellow Research Institute at the Ohio State University since that time and received multiple regimens including fludarabine and Rituxan based regimens under the care of John Byrd, MD. He progressed and more recently was on the clinical trial of ibrutinib for relapsed CLL, which he tolerated well and to which he had an excellent response for nearly 2 years. The patient developed resistance to ibrutinib and was taken off study. According to Dr. Byrd, DNA sequencing revealed a V600 mutation (personal communication). The patient was subsequently enrolled on a clinical trial of carfilzomib, to which he did not respond and developed increasing leukocytosis with increasing numbers of prolymphocytes and transformation to B-cell PLL. He was treated with single agent ofatumumab with transient responses and rapid regrowth. He was then referred to the clinic at the Penn State Hershey State College satellite facility for care closer to his home. Ibrutinib is a novel oral inhibitor of the bruton tyrosine kinase (BTK) which is a member of the Tec family of kinases and is downstream of the B-cell receptor. A Phase 1b-2 study of ibrutinib in patients with relapsed or refractory CLL or small lymphocytic lymphoma was recently conducted. Treatment with Ibrutinib was associated with durable remissions in this population including those with high-risk genetic mutations (Byrd et al NEJM 2013;369:32-42). We have previously shown that immunotherapy combined with epigenetic pharmacotherapy is a feasible strategy in non-Hodgkin's lymphoma (NHL) and CLL in a phase 2 study (NCT 00764517) initiated by Epner and colleagues (Spurgeon et al 2012 ASH abstract 3675, Hasanli et al 2013 AACR LB-140) in which a 100% response rate was observed in untreated mantle cell lymphoma using SAHA (Vorinostat), cladribine and Rituxin (SCR). Based on these results, we proposed a treatment strategy which would employ the same epigenetic pharmacotherapy of SAHA and cladribine in combination with the immunotherapy of ofatumumab. Dr. Byrd agreed with our treatment strategy. Therefore, the epigenetic drugs, SAHA and cladribine combined with ofatumumab were initiated to try to overcome resistance mediated by epigenetic mechanisms as a means to improve therapeutic efficacy.The patient received 5 days of SAHA (400mg PO daily) and cladribine (5mg/m2) and continuied to receive ofatumumab (2000mg IV), and had a dramatic decline in his white blood count from 230 K/uL to 25 K/uL over a period of 10 days. After 3 cycles of our epigenetic immunotherapy, he achieved a complete hematologic remission which is sustained for nearly 12 months. He receives ofatumumab maintenance therapy (2000mg IV every 60 days). Here, we have used ofatumumab in combination with epigenetic pharmacotherapy in a ofatumumab refractory patient with CLL who acquired a 17p deletion to overcome ibrutinib resistance. The mechanism of resistance to ibrutinib in this case and others has not been determined, but sequencing studies carried on in the lab of Dr. Byrd (personal communication) reveal the BRAF V600E mutation. We describe here a patient with CLL who progressed through multiple therapies including ibritunib who achieved a complete hematologic response with the combination of SAHA, cladrbine, and ofatumumab. In this case, epigenetic modulation with pharmacologic intervention consisting of a hypomethylating agent in combination with a histone deacetylase may have enhanced the activity of ofatumumab and overcame ibrutinib resistance. Furthermore, our data suggests that the combination of epigenetic agents with monoclonal antibodies should be studied and that epigenetic agents are potentially capable of activating multiple silenced genes in different pathways. The epigenetic approach and use of hypomethylation agents in CLL deserve further investigations. This particular case demonstrates that (by current standards) a most promising drug (Ibrutinib) has some failures and the epigenetic approach may provide a strategy to salvage these patients. Disclosures: Sharma: Celgene: Consultancy, Employment. Off Label Use: Cladribine: approved for Hairy Cell Lymphoma (HCL), used here to treat B-CLL Vorinostat: approved for Cutaneous T Cell Lymphoma (CTCL), used here to treat B-CLL.
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Lee, Dong-Yun, A. K. M. Kafi, Won-Suk Choi, Sang-Hyun Park, and Young-Soo Kwon. "Glucose Sensor Based on Glucose Oxidase-Lipid LB Film Immobilized in Prussian Blue Layer." Journal of Nanoscience and Nanotechnology 8, no. 9 (2008): 4543–47. http://dx.doi.org/10.1166/jnn.2008.ic04.
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The structure and dynamic organization of a mixed Langmuir film of glucose oxidase (GOx) and lipid at the air–water interface were studied. The film was transferred onto the Prussian Blue (PB)-modified Pt electrode for biosensor preparation. The PB modified electrode showed well defined redox peaks in 0.1 M PBS electrolyte. The Langmuir film was characterized at the air–water interface by π-A isotherms. The mixed monolayer was formed by spreading GOx on the LB trough covered with lipid. Time-pressure results show that at least 90 minutes are required to reach the equilibrium state of GOx-lipid film. The monolayer was transferred onto the PB-modified electrode when surface pressure was 40 mN/m. This sensor was characterized by a very low detection limit and a wide linear range. The optimal conditions for both fabricating and response of the sensor were investigated. The proposed biosensor showed a linear calibration range from 5 × 10−6 to 6 × 10−5 M. The detection limit was determined to be 1.5 × 10−6 M.
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McCormick, Stanley R., Craig W. S. Howe, Pierre Brousset, et al. "Myeloproliferative Neoplasm Resembling Polycythemia Vera In a Patient with t(2;11)(p21;q23) Translocation and Persistently Elevated MiR-125b-1." Blood 116, no. 21 (2010): 5067. http://dx.doi.org/10.1182/blood.v116.21.5067.5067.
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Abstract Abstract 5067 Background: Hematologic neoplasms associated with the chromosomal translocation t(2;11)(p21;q23) form a distinct genetic entity with diverse manifestations, and have been strongly linked with up-regulation of the microRNA miR-125b-1 (Bousquet et al, J Exp Med, 2008). Of 41 patients with myeloid malignancies and t(2;11)(p21;23) reported in the world's literature, all but 2 were cases of acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS), the latter cases frequently high-grade MDS transforming to AML. In 20 of 41 cases deletion of 5q was detected as a secondary cytogenetic abnormality. Only two cases of chronic myeloproliferative disorders associated with t(2;11)(p21;23) have been reported: one of chronic myeloid leukemia with a secondary t(9;22) (Ph) translocation (Royer-Pokora et al, Leukemia, 2003) and one of polycythemia vera (Acar et al, Amer J Hematol, 2006). We encountered a patient with a mixed myelodysplastic/myeloproliferative neoplasm clinically resembling polycythemia vera that was associated with t(2;11)(p21;q23) who was found to have persistent elevation in the blood of the microRNA miR-125b-1. Case Report: A 52 year-old male presented with upper extremity pain and headache. A CBC revealed the white blood cell count was 12.5 ×103/uL (55% neutrophils, 12% lymphocytes, 8% monocytes, 5% eosinophils, 21% basophils), red blood cell count 6.62 × 106/uL, hemoglobin 22.4 g/dL, hematocrit 68.1%, MCV 103 fL, and platelets 112 × 103/uL. Bone marrow aspiration and biopsy revealed a markedly hypercellular marrow (100%) with 1+ reticulin fibrosis, mild trilineal dysplastic morphology, and a blast count of 0.8%. Cytogenetic studies disclosed 46, XY, t(2;11)(p21;q23) [4]/46, idem, del (5)(q15q31) [4]/46, XY, del (5) (q13q31) [2]/46, XY[10]. FISH studies were negative for BCR/ABL1 fusion and MLL rearrangement. Molecular analysis for the JAK2V617F allele was negative. A diagnosis of mixed myelodysplastic/myeloproliferative neoplasm, unclassified was made (WHO 2008). The patient was begun on hydroxyurea, 500 mg daily. Four months after diagnosis the blood counts were within normal range, at which time quantitative real-time PCR (qRT-PCR; Bousquet et al, J Exp Med, 2008) performed on a sample of whole blood revealed a twenty-fold elevation of the microRNA species miR-125b-1, compared to healthy donors (n=3), and JAK2V617F-negative (n=3) and JAK2V617F-positive (n=2) polycythemia vera controls. Repeat qRT-PCR performed on whole blood 15 months after diagnosis confirmed persistently elevated miR-125b-1, nearly 200-fold above healthy donor controls (n=3). 18 months after diagnosis the patient remains healthy, with normal blood counts on 500 mg of hydroxyurea daily (white blood cell count 5.54 ×103/uL, red cell count 5.35 × 106/uL, hemoglobin 13.7 g/dL, hematocrit 47.2%, MCV 88.2, platelets 132.0 × 103/uL). Conclusion: This case expands the clinical-pathologic spectrum of hematologic malignancies associated with t(2;11)(p21;23), and confirms the link between t(2;11)(p21;23) and up-regulation of miR-125b-1. Translocation t(2;11)(p21;23) with miR-125b-1 up-regulation should be considered as a rare possibility in the differential diagnosis of JAK2V617F-negative polycythemia vera. Disclosures: No relevant conflicts of interest to declare.
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Salat-Canela, Clàudia, María José Muñoz, Marta Sesé, Santiago Ramón y Cajal, and Trond Aasen. "Post-transcriptional regulation of connexins." Biochemical Society Transactions 43, no. 3 (2015): 465–70. http://dx.doi.org/10.1042/bst20150033.
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Gap junctions allow intercellular communication. Their structural subunits are four-transmembrane proteins named connexins (Cxs), which can be post-transcriptionally regulated by developmental and cellular signalling cues. Cx translation and mRNA stability is regulated by miRNAs and RNA-binding proteins (RBPs) such as human antigen R (HuR). In addition, several Cxs have also been suggested to contain 5′ internal ribosome entry site (IRES) elements that are thought to allow cap-independent translation in situations such as mitosis, stress and senescence. Furthermore, several recent reports have documented internal translation of Cx mRNAs that result in N-terminally truncated protein isoforms that may have unique gap junction-independent functions [Ul-Hussain et al. (2008) BMC Mol. Biol. 9, 52; Smyth and Shaw (2013) Cell Rep. 5, 611–618; Salat-Canela et al. (2014) Cell Commun. Signal. 12, 31; Ul-Hussain et al. (2014) J. Biol. Chem. 289, 20979–20990]. This review covers the emerging field of the post-transcriptional regulation of Cxs, with particular focus on the translational control of Cx 43 and its possible functional consequences.
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Oluwole, Olalekan O., William Wu, Steven N. Wolff, and Kenneth R. Hande. "Racial differences in the pattern of hematologic toxicity in the treatment of colorectal cancer." Journal of Clinical Oncology 30, no. 4_suppl (2012): 679. http://dx.doi.org/10.1200/jco.2012.30.4_suppl.679.
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679 Background: 5-fluorouracil (5-FU), a synthetic fluoropyrimidine, is a critical component of chemotherapy in many cancers. Its metabolites inhibit Thymidylate Synthetase (TS) causing cessation of DNA synthesis and are misincorporated into DNA and RNA causing ineffective DNA repair and faulty mRNA splicing. The rate limiting step in the catabolism of 5-FU is by the Dihydropyrimidine Dehydrogenase enzyme (DPD) which catabolizes over 80% of 5-FU. Patients with near total DPD enzymatic deficiency develop life threatening toxicity after a single administration and those with less severe deficiency will have delayed elimination of 5-FU and slowly accumulate active metabolites leading to toxicities. Methods: We conducted a pilot retrospective cohort study of African American (AA) and Caucasian patients treated for colorectal cancer over a 9 year period, 2000 – 2008, in this IRB approved study. The primary outcome of interest was the rate of development of grade 3 or 4 neutropenia (Absolute Neutrophil Count <1000/uL = grade 3 and <500/uL = grade 4). Descriptive and univariate analysis were done. To test for differences between AA and Caucasians, we computed independent t-test for continuous and Fisher’s exact test for categorical variables. Relative Risk (RR) and p-values were computed. All statistics were done with SPSS v19 software. Results: There were 66 evaluable patients (40 men, 26 women), 40 AA, 24 Caucasians and 2 of other races. Thirty-eight patients (15 Caucasians and 23 AA) received 5-FU containing chemotherapy. The two groups were comparable in baseline characteristics. AA were more likely to develop grade 3-4 hematological toxicity. Nine of 23 AA (39.1%) and one of 15 Caucasians (6.7%) developed grade 3-4 hematological toxicity. RR 8.56, 95% confidence interval 0.95 – 421.06 (p-value of 0.0561) Conclusions: These results suggest that AA were more likely than Caucasians to have severe hematologic toxicity with the use of 5-FU containing chemotherapy. This difference did not meet statistical significance due to small sample size and few numbers of events in the Caucasian arm. A larger prospective study is needed to further evaluate the observed difference.
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Seetharam, Mahesh, Olga K. Weinberg, Li Ren, et al. "AML Patients with Monosomal Karyotype Are Characterized by Absence of NPM1 and FLT3 Mutations and Worse Clinical Outcome." Blood 114, no. 22 (2009): 2638. http://dx.doi.org/10.1182/blood.v114.22.2638.2638.
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Abstract Abstract 2638 Poster Board II-614 Background: The importance of cytogenetics in prognosis of AML is now widely recognized and accepted in clinical practice. A recent study found that autosomal chromosomal monosomy predicted for an adverse outcome. The goal of this study is to characterize patients with monosomal karyotype by mutation status and clinical features. Methods: One-hundred forty consecutive AML patients diagnosed at Stanford University Hospital between 2005 and 2008 with adequate material for mutation analysis were studied. Cases were classified using the 2008 WHO criteria. Diagnostic cytogenetic findings were reviewed and patients were stratified into risk groups using Southwest Oncology Group criteria. An abnormality was considered clonal when at least two metaphases had the same aberration, except for clonal monosomy, which required at least three metaphases. The karyotype analysis was based on 20 or more metaphases. All samples were tested for NPM, FLT3 (ITD and D835) and CEBPA mutations. Clinical parameters including hemogram data at time of diagnosis were reviewed. Clinical follow-up including overall survival (OS), progression free survival (PFS) and complete remission (CR) rates were retrospectively determined. Kaplan-Meier methods and univariate Cox proportional hazards regression analysis were used to compare the clinical data. Results: The cases included 77 males and 63 females with a median age of 58 (range 17-83). Cytogenetic risk-group stratification resulted in 14 patients with favorable, 88 with intermediate and 28 with unfavorable risk status. Loss of one or more autosomal chromosomes was present in 18 /130 patients (13.8%) with available cytogenetic studies. A single autosomal monosomy was found in 5 patients while 13 patients had two or more autosomal monosomies. The most common chromosomes lost in these 18 patients included 7 (55% of 18 cases), 5 (50%), 17 (33%), 21 (22%), 20 (22%), 22 (17%) and 18 (11%). Using the 2008 WHO criteria, there were 66 AML with myelodysplasia-related changes (AML-MRC), 55 AML not otherwise specified (AML-NOS), 14 AML with either t(8;21), inv(16) or t(15;17) and 5 therapy related AMLs. Overall, 35 patients (25% of all patients) had a NPM1 mutation (19 of which were FLT3 mutated), 33 had FLT3-ITD mutation (24%), 11 had FLT3-D835 (8%) and 11 had a CEBPA mutation (8%) (4 of which were FLT3 mutated). Patients with monosomal karyotype were significantly older (83 vs. 59 years, p=0.0125) and presented with lower WBC (34 vs. 66 K/uL, p=0.0006), lower platelets (41 vs. 64 K/uL, p=0.0111), and lower blasts (38% vs. 65%, p=0.0030) as compared to the rest of AML patients. In addition, patients with monosomal karyotype were more frequently diagnosed with AML-MRC (16/18 vs. 48/107, p=0.0034) and exhibited a decreased frequency of NPM1 mutation (0/18 vs. 28/107, p=0.0138) and FLT3-ITD mutation (0/18 vs. 29/107, p=0.0117). Clinical outcome data showed that patients with monosomal karyotype had a significantly worse OS, PFS and CR compared to the rest of AML patients (OS p=0.001, PFS p=0.002 and CR p=0.0262). Dividing patients by number of monosomies showed that patients with 2 or more monosomies had a significantly worse OS (p=0.0001) and PFS (p=0.0045) than patients without any monosomies. However, no difference in OS or PFS was seen when comparing patients with 1 monosomy to those with 2 or more monosomies. Within the AML-MRC group, monosomal karyotype correlated with lower WBC (17 vs. 37 K/uL, p=0.0005), lower platelets (21 vs. 35 K/uL, p=0.0095), lower blasts (19% vs. 36%, p=0.0015) and shorter OS (p=0.0322) and PFS (p=0.0084). Conclusion: AML patients with monosomal karyotype exhibit a significantly worse OS, PFS and lower CR as compared to other AML patients. Most of patients fall within the newly defined AML-MRC group and are characterized by significant absence of NPM1 and FLT3-ITD mutations. Disclosures: No relevant conflicts of interest to declare.
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Mahadeo, Kris Michael, Suzette Oyeku, Karen Moody, et al. "Hydroxyurea Use Is Associated with Avascular Necrosis of the Femoral Head among Children with Sickle Cell Disease." Blood 112, no. 11 (2008): 2477. http://dx.doi.org/10.1182/blood.v112.11.2477.2477.
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Abstract Hydroxyurea therapy is associated with reduced morbidity among patients with sickle cell disease (SCD). Avascular necrosis of the femoral head (AVN) is one potentially debilitating complication of SCD. In this study, we examined the relationship between hydroxyurea use and the prevalence of AVN among children with SCD. We performed a retrospective chart review of 202 children with SCD, aged 10–21 years, followed in the pediatric hematology program at the Children’s Hospital at Montefiore (Bronx, NY) between July 2007 and 2008. Abstracted data included age, ethnicity, SCD genotype, frequency of hospitalization, hip radiograph results, laboratory data and hydroxyurea use. Hip radiographs were performed prospectively as part of SCD health maintenance from 2005–2008. Forty-four patients were excluded because they did not have a screening hip radiograph. Descriptive statistics were calculated for independent variables. T-tests and chi-square tests were used to compare clinical and demographic characteristics of children with and without AVN. Multivariate logistic regressions were used to estimate the odds ratio of having AVN among SCD patients. Our final sample consisted of 158 patients whose demographic characteristics are listed in Table 1. The prevalence of AVN was 16.5% (n=26). Of the clinical variables analyzed, we identified significant associations between the presence of AVN and hydroxyurea use (p=.005), as well as older age (p=.013) (Table 1.) Children with AVN had significantly lower mean lactic dehydrogenase levels (LDH) (p=.04) and higher mean corpuscular volumes (MCV) (p=.012). (Table 2.) After controlling for gender, ethnicity, sickle cell genotype, and frequency of hospitalizations, age was also found to be associated with AVN (OR 1.15, 95% confidence interval (CI): 1.01,1.31, p=0.033). SCD patients on hydroxyurea had higher odds of having AVN compared to non-users (OR 3.51, 95% CI: 1.31, 9.38, p= 0.013). Laboratory values (MCV, Hemoglobin, LDH and Hematocrit) had a high degree of collinearity and were removed from the final model. In summary, the prevalence of AVN in our sample was 16.5%. This is substantially higher than the prevalence of approximately 6% reported by the Cooperative Study of Sickle Cell Disease for comparative age groups in a prospective study1. SCD patients exposed to hydroxyurea were three times more likely to have AVN than those not exposed to this drug. Vaso-occlusive pain crisis is a recognized risk factor for AVN, thus we could expect a higher rate of AVN among patients on hydroxyurea. However, the odds ratio of 3.5 is unexpectedly high and warrants further investigation into the role of hydroxyurea as a risk factor for AVN. Nonetheless, these preliminary results suggest that more stringent screening regimens for AVN may be indicated among this subset of patients. Table 1. Clinical characteristics of patients with and without avn *p&lt;0.05 **p&lt;0.01 No AVN (N =132) AVN (N = 26) Age * 15.7 years 17.4 years Sex Male 64 (49%) 17 (65%) Ethnicity Black 110 (83%) 23 (88%) Hispanic 22 (17%) 3 (12%) HgbSS 84 (64%) 20 (77%) HgbSC 38 (29%) 4 (15%) HgbSBthal0 5(3.8%) 2 (8%) Hgb SC HgbSBthal+ 5 (3.8%) 0 On Hydroxyurea** 38 (29%) 15 (58%) # Hospitalizations 0 60 (45%) 10 (38%) 1–5 64 (49%) 14 (54%) &gt;5 8 (6%) 2 (8%) Table 2. Mean Laboratory Values for Patients With And Without AVN No AVN AVN *p&lt;0.05 (N =132) (N = 26) WBC 10.7 k/uL 10.5 k/uL Hgb 9.4 gm/dL 9.6 gm/dL MCV* 83 fL 89 fL Platelets 381 k/uL 376 k/uL Reticulocyte 7.70% 8.10% Ferritin 369.8 ng/mL 438.7 ng/mL LDH* 471.6 U/L 389 U/L Creatinine 0.6 mg/dL 0.6 mg/dL Hgb F 9.80% 11.30%
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Rahayuningsih, Fransisca. "Survei Peningkatan Mutu Berkelanjutan Melalui Pemantauan dan Pengukuran Kepuasan Pemustaka." Berkala Ilmu Perpustakaan dan Informasi 11, no. 2 (2016): 16. http://dx.doi.org/10.22146/bip.10031.
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Two keywords in implementing Quality Management System ISO 9001:2008 are customer satisfaction and continuous improvement. Both are important and always influence each other. In the practice of library service, user satisfaction becomes an essential aspect for the library to make a continuous improvement. This means when a library puts priority on user satisfaction, it will make continuous improvement. In other words, a continuous improvement will always be made when the library concentrates on achieving user satisfaction. This study is aimed at identifying the achievement level ofuser satisfaction reached at Sanata Dharma University Library (SD UL) in the period of 2008 to 2014 and to find out continuous improvement that has been made by SDUL, especially, the result analysis on monitoring and assessing user satisfaction. This study was a survey that used descriptive method. The result of the study showed the achievement level of monitoring and assessmentof user satisfaction at SDUL in the period of 2008 to 2014 reached maximum score, that is, 3.5 to 3.8 in the scale of I to 5. Observed from the user satisfaction analysis, continuous quality improvement conducted in SDUL covered three important fields, that is, information and information access facilities, library services, and infrastucture and work environment. Keywords: library user satisfaction, collection and information access, library services, infrastructure and work environment
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Beltran, Brady E., Erick Cotacallapa, and Jorge J. Castillo. "Monocytosis As Prognostic Factor in Aggressive, Non-Primary Cutaneous Peripheral T-Cell Lymphoma: A Study of 251 Cases." Blood 120, no. 21 (2012): 1608. http://dx.doi.org/10.1182/blood.v120.21.1608.1608.
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Abstract Abstract 1608 Background: Peripheral T-cell lymphoma (PTCL) is a heterogeneous family of entities with a worse prognosis, stage by stage, than their B-cell counterparts. We have previously reported that an absolute lymphocyte count (ALC) <1000/uL is associated with a worse prognosis in Peruvian patients with PTCL (Castillo et al. 2010). The goal of this study is to investigate the prognostic value of absolute monocyte count (AMC) in the survival of patients with PTCL. Methods: A total of 251 cases of aggressive, non-primary cutaneous PTCL diagnosed at our institution between January 1997 and January 2012 were reviewed, reevaluated according to their morphological, immunological and clinical characteristics, and reclassified according to the 2008 WHO classification of lymphoid neoplasms. Characteristics will be presented descriptively. Kaplan-Meier method was used to estimate overall survival (OS) curves, which were compared using the log-rank test. The multivariate analysis was performed using the Cox proportional-hazard regression test. Results: According to the new WHO classification of lymphoid neoplasms, 104 cases (41%) were classified as adult T-cell leukemia/lymphoma (ATLL), 103 cases (41%) as PTCL, unspecified (PTCLU), 27 cases (11%) as analplastic lymphoma kinase (ALK)-negative anaplastic large cell lymphoma (ALCL), 11 cases (4%) as extranodal NK/T-cell lymphoma (NKTCL), nasal type, 4 cases (2%) as angioimmunoblastic lymphoma (AIL), and 2 cases (1%) were diagnosed with ALK+ ALCL. The median age at diagnosis was 57 years (range 14–92 years); 47% of patients were >60 years. The male-to-female ratio was 1:1. ECOG performance status >1 was seen in 51%, LDH was elevated in 67%, advanced stage was seen in 73%, and >1 extranodal sites were seen in 22% of the patients. Bone marrow involvement was reported in 30% and B symptoms in 64% of patients. An International Prognostic Index (IPI) score 3–5 was seen in 55%, and a Prognostic Index for PTCLU (PIT) score of 2–4 in 63%. The median overall survival (OS) for the whole group was 10 months. The IPI score, the PIT score, ALC <1000/uL and AMC >800/uL (Figure) showed statistical significance in the univariate survival analysis (p<0.001, p<0.001, p=0.001 and p=0.001, respectively). In the multivariate analysis, PIT score and AMC >800/uL showed statistical significance (p=0.006, p=0.046, respectively). Conclusions: Monocytosis, defined as AMC >800/uL, and the PIT score were independent prognostic factors for OS in patients with aggressive, non-primary cutaneous PTCL. Disclosures: No relevant conflicts of interest to declare.
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Drullinsky, P., M. N. Fornier, S. Sugarman, et al. "Dose-dense (DD) cyclophosphamide, methotrexate, and fluorouracil (CMF) at 14-day intervals: A pilot study of every 14- and 10–11-day dosing intervals for women with early-stage breast cancer." Journal of Clinical Oncology 27, no. 15_suppl (2009): 590. http://dx.doi.org/10.1200/jco.2009.27.15_suppl.590.
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590 Background: CMF (C 600 mg/m2, M 40 mg/m2, F 600 mg/m2) is an option for adjuvant therapy for patients with low risk early stage breast cancer. DD regimens as predicted by mathematical models of cancer growth and treatment response are superior. We previously demonstrated the safety of DD EC (epirubicin/cyclophosphamide) followed by paclitaxel at 10–11 day (d) intervals. We investigated the feasibility of administering DD adjuvant CMF every 14 d and then every 10–11 d in a 2-stage phase II trial. Methods: An initial cohort (A) was treated q 14 d with PEG-filgrastim (Neulasta) support. A second cohort (B) was treated every 10–11 d with filgrastim/Neupogen x 5 d and then, based on feasibility, modified (cohort C) to use 7 d filgrastim. The primary end point was feasibility defined as having ANC > 1.5 x 103/uL on day 1 of planned treatment for all 8 cycles with no grade 3 or higher non-hematologic toxicity. All three cohorts were tested using a Simon's two-stage optimal design with type I and type II errors set at 10%. This design would effectively discriminate between true tolerability (as protocol-defined) rates of< 60% and> 80%. Cohort A: 38 pts with early stage breast cancer were accrued from 3/2008 though 6/2008. Cohort B: 7 pts were accrued from June 2008 through August 2008. Cohort C: Is still open with 16 pts accrued from August 2008 through December 5, 2008. Results: Median age 51: range 38 to 78. Cohort A: 29/38 pts completed 8 cycles of CMF. The regimen was considered feasible. 2 other pts completed 7 cycles and were withdrawn for depression and grade 2 transaminitis. The 7 other pts completed between 1 and 6 cycles of CMF were withdrawn as follows: 3 personal, 1 (grade 3) bone pain, 2 allergy unrelated to CMF, and 1 seizure. Cohort B: 7 pts were accrued. 6 out of 7 pts could not complete 8 cycles of chemotherapy secondary to neutropenia and 1 secondary to grade 3 ALT elevation. Cohort C: Accrual has not been completed. 16 pts are currently enrolled. Conclusions: Dose dense adjuvant CMF is feasible at 14 d intervals with PEG-filgrastim support. Adjuvant CMF every 10–11 days with filgrastim given for 5 days beginning day 2 is not feasible. Accrual is ongoing for CMF at 10–11 days with filgrastim x 7 days. Updated results will be available for Cohort C. [Table: see text]
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Stumpf, Anita N., Edith D. van der Meijden, Cornelis A. M. van Bergen, Roelof Willemze, J. H. Frederik Falkenburg, and Marieke Griffioen. "Identification of Four New HLA Class II Restricted Minor Histocompatibility Antigens Contributing to Graft Versus Leukemia Reactivity." Blood 112, no. 11 (2008): 3247. http://dx.doi.org/10.1182/blood.v112.11.3247.3247.
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Abstract Patients with relapsed hematological malignancies after HLA-matched hematopoietic stem cell transplantation (HSCT) can be effectively treated with donor lymphocyte infusion (DLI). Donor-derived T cells mediate beneficial graft-versus-leukemia (GvL) effect but may also induce detrimental graft-versus-host disease (GvHD). These T cell responses are directed against polymorphic peptides which differ between patient and donor due to single nucleotide polymorphisms (SNPs). These so called minor histocompatibility antigens (mHag) are presented by HLA class I or II, thereby activating CD8+ and CD4+ T cells, respectively. Although a broad range of different HLA class I restricted mHags have been identified, we only recently characterized the first autosomal HLA class II restricted mHag phosphatidylinositol 4-kinase type 2 beta (LB-PI4K2B-1S; PNAS, 2008, 105 (10), p.3837). As HLA class II is predominantly expressed on hematopoietic cells, CD4+ T cells may selectively confer GvL effect without GvHD. Here, we present the molecular identification of four new autosomal HLA class II restricted mHags recognized by CD4+ T cells induced in a patient with relapsed chronic myeloid leukemia (CML) after HLAmatched HSCT who experienced long-term complete remission after DLI with only mild GvHD of the skin. By sorting activated CD4+ T cells from bone marrow mononuclear cells obtained 5 weeks after DLI, 17 highly reactive mHag specific CD4+ T cell clones were isolated. Nine of these T cell clones recognized the previously described HLADQ restricted mHag LB-PI4K2B-1S. The eight remaining T cell clones were shown to exhibit five different new specificities. To determine the recognized T cell epitopes, we used our recently described recombinant bacteria cDNA library. This method proved to be extremely efficient, since four out of five different specificities could be identified as new HLA-class II restricted autosomal mHags. The newly identified mHags were restricted by different HLA-DR molecules of the patient. Two mHags were restricted by HLA-DRB1 and were found to be encoded by the methylene-tetrahydrofolate dehydrogenase 1 (LBMTHFD1- 1Q; DRB1*0301) and lymphocyte antigen 75 (LB-LY75-1K; DRB1*1301) genes. An HLA-DRB3*0101 restricted mHag was identified as LB-PTK2B-1T, which is encoded by the protein tyrosine kinase 2 beta gene. The fourth mHag LB-MR1-1R was restricted by HLA-DRB3*0202 and encoded by the major histocompatibility complex, class I related gene. All newly identified HLA class II restricted mHags exhibit high population frequencies of 25% (LB-MR1-1R), 33% (LB-LY75-1K), 68% (LB-MTHFD1- 1Q), and 70% (LB-PTK2B-1T) and the genes encoding these mHags show selective (LY- 75) or predominant (MR1, MTHFD1, PTK2B) expression in cells of hematopoietic origin as determined by public microarray databases. All T cell clones directed against the newly identified mHags recognized high HLA class II-expressing B-cells, mature dendritic cells (DC) and in vitro cultured leukemic cells with antigen-presenting phenotype. The clone recognizing LB-MTHFD1-1Q also showed direct recognition of CD34+ CML precursor cells from the patient. In conclusion, we molecularly characterized the specificity of the CD4+ T cell response in a patient with CML after HLA-matched HSCT who went into long-term complete remission after DLI. By screening a recombinant bacteria cDNA library, four new different CD4+ T cell specificities were characterized. Our screening method and results open the possibility to identify the role of CD4+ T cells in human GvL and GvHD, and to explore the use of hematopoiesis- and HLA class II-restricted mHag specific T cells in the treatment of hematological malignancies.
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Vera, L., R. Reategui, B. Beltran, et al. "The clinicopathological spectrum of HIV-associated lymphoma: Eleven-year-experience in a general hospital in Peru." Journal of Clinical Oncology 27, no. 15_suppl (2009): e19561-e19561. http://dx.doi.org/10.1200/jco.2009.27.15_suppl.e19561.
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e19561 Background: The clinicopathological spectrum of HIV-associated lymphomas in developing countries has not been clearly defined. Thus, this study is aimed to describe these features in cases from a Peruvian population. Methods: This is a retrospective review of the clinical records of patients with diagnosis of HIV in our institution from March 1997 to March 2008. We reviewed 2502 clinical records. The statistical method was descriptive and survival was calculated using the Kaplan-Meier method. Results: Forty-eight patients with HIV-associated lymphoma were identified. Male:female ratio was 15:1. Median age was 42 years (range 27 to 70). 32 patients (67%) had clinical stage III-IV, B symptoms 35 (73%), the International Prognostic Index was low-risk 20 patients (42%), low-intermediate risk 15 patients (31%), high-intermediate risk 10 patients (21%) and high-risk 3 patients (6%). CD4 count lower than 100 cells/uL was 11 patients (23%). The CD4 count median was 184 cells/uL. The nodal localization in 27 patients (56%) was lightly higher. Forty-four cases (92%) were diagnosed with non-Hodgkin lymphoma (NHL) and 4 cases (8%) with Hodgkin lymphoma (HL). From the 44 NHL cases, 40 cases (91%) were of B-cell origin; 23 cases (57.5%) had diffuse large B-cell, 9 cases (22.5%) had Burkitt, 3 cases (7.5%) had plasmablastic, 2 cases (5%) had primary CNS, 2 cases (5%) had MALT and 1 case (2.5%) had primary effusion lymphoma. The remaining 4 cases (9%) were of T-cell origin; 3 cases (75%) had peripheral T-cell lymphoma NOS and 1 case (25%) was ALK-negative anaplastic large cell lymphoma. Only 16 patients (33%) were receiving HAART previously the diagnosis of NHL and 33 patients (68%) received any oncology treatment. Conclusions: This entity is aggressive and frequently has extranodal involvement. Also a high proportion of T-cells lymphomas are found. These findings are in concordance with one prior report of another general hospital from Peru. No significant financial relationships to disclose.
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Sekeres, Mikkael A., Paul Elson, Ramon V. Tiu, et al. "Validating the Lower-Risk MD Anderson Prognostic Scoring System (LR-PSS) and the Revised International Prognostic Scoring System (IPSS-R) for Patients with Myelodysplastic Syndromes." Blood 118, no. 21 (2011): 1720. http://dx.doi.org/10.1182/blood.v118.21.1720.1720.
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Abstract Abstract 1720 Background: The myelodysplastic syndromes are commonly divided into lower- and higher-risk subtypes depending on blast percentage and International Prognostic Scoring System (IPSS) score (0–1.0, low or Int-1, median overall survival (OS) 3.5–5.7 years). Because the IPSS is limited in its ability to identify poor prognosis lower-risk patients (pts), a prognostic scoring system specifically for lower-risk MDS pts (LR-PSS) was developed (Garcia-Manero Leukemia 2008) at MD Anderson (MDA), based on unfavorable (non-del(5q), non–diploid) cytogenetics, hemoglobin (hgb) <10g/dl, platelet count (plt) <50 k/uL or 50–200k/uL, bone marrow blast %≥4, and age ≥60 years. The IPSS-R (Greenberg Leuk Res 2011) improves upon the IPSS using novel cytogenetics classifications (Schanz EHA 2010) and a neutrophil cut-off of 800 k/uL. We validated the LR-PSS and the IPSS-R in a separate cohort of lower-risk MDS patients seen at Cleveland Clinic (CC) or at MDA not included in LR-PSS development. Methods: Of 1293 MDS patients identified at CC or MDA from 1991–2010, 664 had lower-risk disease and adequate data for analyses. OS was calculated from first date seen at either institution. The Kaplan–Meier method was used to estimate median OS. Univariable analyses were performed using the log-rank test; multivariable analyses used a Cox proportional hazards model stratified by treatment center. Harrell's c index and the Akaike information criteria (AIC) were used to assess the discriminatory power of the models and relative goodness of fit, respectively. Results: Comparing CC to MDA, baseline values were similar except median age: 70 vs. 67 years (p=.02); time since diagnosis: 2.7 vs. 1.1 months (p<.0001); hgb <10: 51% vs. 43% (p=.05); plt <50k/uL: 30 vs. 24% (p=.06); ANC <1.5 k/uL: 27% vs. 36% (p=.01); blasts <4%: 75% vs. 65% (p=.003); WHO classification RA/RARS/RCMD/CMML: 11/15/26/12% vs. 16/9/45/0% (p<.0001). Cytogenetics were diploid: 61% vs. 66%; del(5q): 9% vs. 2%; del(20q): 3% vs. 5%; -Y: 4% vs. 2%, respectively (p=.5). Median OS was 36.8 months (95% C.I. 33–45) and median follow-up of patients still alive was 13.9 months (range 0.01–155). LR-PSS and IPSS-R classifications for CC and MDA Pts and OS are in Table 1 and Figure 1. In univariable analyses, The IPSS, LR-PSS, and IPSS-R were all predictive of OS (p=.002, <.0001, and <.0001, respectively). Multivariable analyses confirmed the overall predictive abilities of the prognostic tools and of Hgb, plt, age, and IPSS/IPSS-R cytogenetics (all p≤.03). Compared to the IPSS-R, the LR-PSS had the higher (better) Harrell's c value (.64 vs.63) and lower (better) AIC (2518 vs. 2525). The LR-PSS upstaged 156 pts (25%) from IPSS low or Int-1 to LR-PSS Category 3, and downstaged 47 pts (12%) from Int-1 to Category 1. The IPSS-R upstaged 164 pts (27%) from IPSS low or Int-1 to IPSS-R Categories ≥Intermediate, and downstaged 5 pts (1%) from Int-1 to Very Good. Conclusions: The LR-PSS and IPSS-R are valid tools for distinguishing among pts previously thought to have lower-risk disease by the IPSS, and identifying those who have better and worse survival. This latter group of pts may benefit from earlier interventions with disease-modifying therapies, and should be considered in trials targeting higher-risk MDS pts. The LR-PSS appears to provide slightly better prognostic information. Disclosures: Sekeres: Celgene: Consultancy, Honoraria, Speakers Bureau. Maciejewski:Celgene: Membership on an entity's Board of Directors or advisory committees.
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Lukina, Anna E., Elena A. Baryakh, Alla M. Kovrigina, et al. "B-Cell Lymphoma Unclassified, Intermediate Between Diffuse Large B-Cell Lymphoma and Burkitt Lymphoma: A Single Center Experience of Intensive Chemotherapy with and without Auto-SCT." Blood 124, no. 21 (2014): 5902. http://dx.doi.org/10.1182/blood.v124.21.5902.5902.
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Abstract Background: According to current data B-cell lymphoma unclassified (BCLU), intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma represents a highly aggressive type of lymphoma with dramatically bad response for chemotherapy. Cases with translocation of two genes (MYC and BCL2 or BCL6) are divided into double-hit lymphomas (DHL). We need to estimate risk factors to intensify treatment and manage indications for autologous stem cell transplantation (auto-SCT) according to individual characteristics. Aim: To evaluate results of BCLU treatment according to LB-M-04±R protocol in adults younger than 60 years old and CHOP-like regimens in elderly patients (≥60 years old) with auto-SCT in high risk patients group. Patients and Methods: 21 pts observed in National Research Center for Hematology (Moscow) between 2004 and 2014 years were included in a current study. All of them were convenient to BCLU diagnosis criteria according to WHO classification of hematological malignancies (2008). Genetic analysis included: standard karyotyping in 7 pts (6 – lymph nodes samples, 1 sample of cerebrospinal fluid). FISH analysis was performed in 21 pts (in 7 cases on tumor cells; on imprints of tumor in 4 cases, on histologic slides from paraffin blocks - in 10 cases). Taking into account heterogeneity of a common group we divided all pts into 2 subgroups: DHL and non-DHL cases (7 vs. 14 respectively). Pts younger than 60 years old (17 pts) were treated according to LB-M-04±R protocol which included A-C-A-C courses. Course A consisted from dexamethasone 10 mg/m2 i.v. 1-5 ds, methotrexate 1500 mg/m2 12-hours infusion 1st d, ifosfamide 800 mg/m2 1-5 ds, vincristine 1 mg/m2 1st d, doxorubicine 50 mg/m2 3rd d, cytarabine 150 mg/m2 4-5 ds, etoposide 100 mg/m2 4-5 ds; course C included dexamethasone 10 mg/m2 i.v. 1-5 ds, methotrexate 1500 mg/m2 12-hours infusion 1st d, vinblastine 5 mg/m2 1st d, cytarabine 2000 mg/m2 twice a day 2-3 ds, etoposide 150 mg/m2 3-5 ds. Rituximab were indicated before chemotherapy in dosage 375 mg/m2. CNS prophylaxis was made by intrathecal administration of prednisolone 30 mg, cytarabine 30 mg, methotrexate 15 mg in 1st day of each course. When complete remission (CR) was achieved after 2 courses, treatment lasted 4 courses. When tumor regression was diagnosed after 4 courses, treatment continued till 6 courses. 4 pts ˃60 years were managed by CHOP-like regimens ±R. We performed auto-SCT in non-DHL group with signs of poor prognosis (bone marrow involvement, multiple extranodal sites, CR after 6 courses) and in DHL when CR had been achieved after 4 courses. Pts with DHL after auto-SCT received 2 R-EPOCH courses more. As a conditional regimen BEAM was used. An overall survival (OS) as a primary endpoint and event-free survival (EFS) were assessed with using the Kaplan-Meier method (with log-rank test) to estimate an efficacy of treatment. Statistical analysis was performed with SAS 9.3 (SAS Institute Inc. Cary, NC). Results: Studying group included 9 males and 12 females. Comparing pts according DH and non-DH status, DHL group (n=7) consisted of 2 males and 5 females, median age 48 years (30-74), ECOG status was 2.6 (95%CI 1.3-3.9) and non-DH group consisted of 7 male and 7 female, median age was 46 (23-76), ECOG status was 2.4 (95%CI 1.8-3.1). DHL pts had stage II of lymphoma according to Ann-Arbor classification in 1 case, III in 1 case, IV in 5 cases. Non-DHL pts had stage II of lymphoma in 2 cases and IV in 12 cases. Bone marrow involvement was revealed in 2 cases in DHL group and in 5 cases in non-DHL group. More than 1 extranodal site took place in 3 cases of DHL and 8 cases of non-DHL. Survival rates of groups were comparable because they were not significantly different of these characteristics. The 2-year OS and EFS rates were less for DHL pts compared with non-DHL pts: OS: 43 vs. 75%, P=0.24 and EFS: 29 vs. 66%, P=0.09 respectively (Figures 1and 2). Auto-SCT was performed in 2 pts with DHL treated by LB-M-04±R protocol (both pts still be alive) and in 3 pts with non-DHL (1 pt treated by LB-M-04±R and 1 treated by CHOP-like regimen+R are alive in CR and 1 pt treated by LB-M-04±R protocol developed a relapse). Conclusions: Low OS and EFS in BCLU group are caused particularly by DHL cases. We need to enlarge an observation group to confirm benefits of auto-SCT in BCLU pts with signs of poor prognosis. Figure 1 Figure 1. Figure 2 Figure 2. Disclosures No relevant conflicts of interest to declare.
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Shastri, Aditi, Ira Braunschweig, Stefan Klaus Barta, et al. "Stimulation of Adrenergic Activity By Desipramine Enhances Hematopoietic Stem and Progenitor Cell Mobilization Along with G-CSF in Multiple Myeloma - a Pilot Study of Safety and Efficacy." Blood 126, no. 23 (2015): 3101. http://dx.doi.org/10.1182/blood.v126.23.3101.3101.
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Abstract Background: Hematopoietic stem cell release is regulated by the sympathetic nervous system through the β (3) adrenergic receptor [Mendez-Ferrer et al. Nature 2008]. Peripheral sympathetic nerve neurons express the G-CSF receptor and stimulation of peripheral sympathetic nerve neurons with G-CSF reduced norepinephrine (NE) reuptake significantly, suggesting that G-CSF potentiates the sympathetic tone by increasing NE availability [Lucas et al Blood 2012]. Based on preclinical data, we investigated the NE reuptake inhibitor desipramine in HSC mobilization. Despite augmentation with Plerixafor (CXCR4 inhibitor), 20% of all patients fail to mobilize 6*10^6 CD34 cells/kg in myeloma and the collection rate with G-CSF alone is 51.1% [Diperiso et al Blood 2012]. The cost of upfront plerixafor is $9,081 per patient while desipramine costs $40. We undertook a feasibility study of adult patients with MM undergoing autologous transplantation (ASCT) to study safety and efficacy of mobilization with desipramine and G-CSF. Patients & Methods: From 2013- 2014, 10 patients between the ages of 18-70, eligible for ASCT were enrolled. Desipramine 100mg daily was administered for 7 days, starting 4 days prior to starting G-CSF (D-3) and continue along with G-CSF for a total of 7 days. CBC and CD34 counts were determined on Day+5. If CD34 counts were > 10/ul, stem cell collection was commenced and if < 10/ul, plerixafor was added as salvage therapy. The endpoints were safety and efficacy in mobilizing CD34 cells for ASCT in patients with multiple myeloma. This trial was registered at clinicaltrials.gov as NCT01899326. Results Six of ten patients enrolled completed the protocol and underwent stem cell transplantation. Reasons for not completing were 1. Lack of insurance coverage 2. Non-compliance with study treatment 3. Disease relapse prior to ASCT. Five patients did not have any grade 3 or 4 adverse events and 1 had disease-related Grade 4 hypercalcemia and Grade 2 AKI at the time of stem cell mobilization. No patients had significant treatment related adverse effects. All 6 patients who completed the protocol achieved the target collection of 5*10^6 CD34 cells/kg. Four patients achieved 6*10^6 CD34 cells/kg or more and the remaining 2 patients achieved 5.52 and 5.92 *10^6 CD34 cells/kg respectively. Among the 6 patients, 2 patients received salvage plerixafor. The median time to achieve WBC >1000/ul, ANC >500/ul and platelets>20k was 11.5, 11, 13.5 days Table 1. Age Ind. Regimne Disease status P PB CD34/ul CD34 collected *10^6 / kg Total CD34/kg collected Engraftment (Days to) Adverse effects from desipramine D1 D2 D3 D4 D2 D3 D4 ANC >0.5 Platelets> 20k G1,G2 G3,G4 1 62 Free λ VRD VGPR N 45.8 66.0 7.01 7.01 12 13 none none 2 50 Free λ VRD VGPR N 88.0 143.5 12.22 12.22 12 12 none none 3 58 IgA VCD VGPR N 38.0 67.7 31.6 4.22 2.75 6.97 13 17 none none 4 70 IgAκ VRD VGPR Y 2.40 40.2 16.6 4.31 1.61 5.92 12 14 none none 5 56 IgGκ VCD VGPR Y 8.70 11.9 37.1 19.4 1.33 4.57 1.61 7.51 11 12 none none 6 70 IgGλ VD RD Relapse N 76.2 97.1 5.54 5.54 11 20 AKI hypercalcemia P-Plerixafor; V-Velcade; R-Lenalidomide; D-Dexamethasone; C-Cyclophosphamide Conclusions Overall G-CSF + Desipramine combination appears to be safe, well tolerated and shows signs of efficacy. G-CSF and desipramine was successful in 4/6 (66%) and all achieved the stem cell collection in 2 days or less. Desipramine, GCSF and Plerixafor was successful in all (6/6) patients to achieve a target of 5*10^6 CD34 cells/kg. The mean number of CD34 cells collected in the desipramine+ G-CSF mobilisers was 7.24*10^6 CD34 cells/kg which, based on historical data, is higher than what would be expected with G-CSF alone even though 3/4 of these patients had lenalidomide as induction therapy. Based on these results, a phase II clinical study evaluating the efficacy of G-CSF with desipramine with or without salvage plerixafor in multiple myeloma and lymphoma will be initiated. Disclosures Barta: Seattle Genetics: Research Funding.
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Morioka, Chie, Masahito Uemura, Tomomi Matsuyama, et al. "Decreased Activity of Plasma ADAMTS13 Parallels Enhanced Endotoxemia in Patients with Severe Acute Pancreatitis: Relationship to Multiorgan Failure." Blood 112, no. 11 (2008): 4541. http://dx.doi.org/10.1182/blood.v112.11.4541.4541.
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Abstract Background: Severe acute pancreatitis (SAP) frequently progresses to pancreatitis-associated multiorgan failure (MOF) with high mortality. Decreased plasma ADAMTS13 activity (ADAMTS13:AC) results in the accumulation of unusually large von Willebrand factor multimers (UL-VWFM) and the formation of platelet thrombi, ultimately leading to MOF. We demonstrated that the imbalance between decreased ADAMTS13:AC and increased UL-VWFM could contribute to SAP pathogenesis through enhanced thrombogenesis, and serve as an early prognostic indicator for SAP patients (Scand J Gastroenterol, 2008, 26:1). Endotoxin has been considered to be the principle activator of the systemic inflammatory response syndrome, which predisposes patients for MOF and/or pancreatic necrosis, ultimately leading to SAP. We investigated the relationship of endotoxin to ADAMTS13:AC and its related parameters, and tried to explore their potential role on the development of MOF in patients with SAP. Methods: We sequentially determined plasma endotoxin concentration, ADAMTS13:AC and its related parameters in 13 SAP patients (APACHE-II score mean 6.6 ± 2.7), who were admitted into intensive care unit of our hospital between 2004 and 2006. Eleven patients were survivors and two were non-survivors whose APACHE II scores were 10 and 12 died of MOF, respectively. The degree of MOF was evaluated according to the SOFA score. Endotoxin concentration was determined by a chromogenic substrate assay (Toxicolor LS –M Set, Seikagaku Kogyo Co.) with kinetic analysis after pretreatment with detergent, Triton X-100, and heating at 70 °C for 10 min. Plasma ADAMTS13:AC was determined by a sensitive chromogenic ELISA (ADAMTS13-act-ELISA: Kainos Inc.). Plasma UL-VWFM was analyzed by a vertical SDS-1.0% agarose gel electrophoresis. Plasma VWF antigen (VWF:AG), interleukin 6 (IL-6), interleukin 8 (IL-8), and tumor necrosis factor -α (TNF-α) were measured by ELISA. Results: In normal healthy controls (n=20), plasma endotoxin concentration was 7.9±1.7 pg/ml (mean ± SD). The concentration in the SAP patients significantly increased at day 1 (means 65 pg/ml, p&lt;0.001) and at day 2 (88 pg/ml, p&lt;0.001) as compared to healthy controls. The values, thereafter, gradually decreased in 8 survivors (55 pg/ml at day 5, 53 pg/ml at day 7, 27 pg/ml at day 14), while in remaining 3 survivors needing necrosectomy, the concentration further increased (98 pg/ml at day 5, 178 pg/ml at day 7), and decreased to 20 pg/ml at day 14 at the recovery phase. In two non-survivors, the endotoxin levels increased from 37 pg/ml at day 1 to 462 pg/ml at day 2 in one needing necrosectomy, and showed 51 pg/ml at day 1 in another at the age of 91. Within 1 or 2 days after admission, the ADAMTS13:AC was lower in SAP patients (mean 29%, p&lt;0.001) than in healthy controls (99%), and gradually recovered in the 11 survivors but further decreased in the 2 non-survivors. On admission, VWF:Ag was higher (402%, p&lt;0.001) in SAP patients than controls (100%). VWF:Ag gradually decreased in the survivors, except in the 3 survivors needing a necrosectomy, but remained high in the non-survivors. UL-VWFM positive patients showed lower ADAMTS13:AC (25% vs. 42%, p&lt;0.05) and higher VWF:Ag ( 481% vs. 332%, p&lt;0.05), resulting in higher ratio of VWF:Ag to ADAMTS13:AC (25.2 vs. 9.1, p&lt;0.02), as compared to UL-VWFM negative ones. Patients with higher endotoxin concentration more than 50 pg/ml showed lower ADAMTS13:AC than those without (22% vs. 43%, p&lt;0.05). Plasma endotoxin concentration positively correlated with the ratio of VWF:Ag to ADAMTS13:AC (r=0.732, p&lt;0.005). The SOFA score correlated positively with plasma endotoxin concentration (r=0.604, p&lt;0.03), IL-8 (r=0.843, p&lt;0.001), and the ratio of VWF:Ag to ADAMTS13:AC (r=0.700, p&lt;0.01), and inversely with the ADAMTS13:AC (r= − 0.601, p&lt;0.03). Conclusion. The imbalance between decreased ADAMTS13:AC and increased UL-VWFM is closely related to enhanced endotoxemia, which may contribute to the development of SAP and subsequent MOF through enhanced thrombogenesis.
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Qiao, Junjing, Dandan Zhao, Le Xuan Truong Nguyen, et al. "Spred1 Insufficiency in the Hematopoietic and/or Vascular Compartments of the Bone Marrow (BM) Niche Promotes Aggressive Leukemogenesis in Chronic Myelogenous Leukemia (CML)." Blood 134, Supplement_1 (2019): 3791. http://dx.doi.org/10.1182/blood-2019-127616.
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Spred1, a member of the Sprouty family of proteins and a negative regulator of RAS-MAPK signaling, is highly expressed in normal hematopoietic stem cells (HSCs) where it negatively regulates self-renewal activity. Lack of Spred1 function has been associated with aberrant hematopoiesis (Tadokoro, 2018). Spred1 knocked-out (KO) mice fed with high-fat diet develop a myeloproliferative phenotype (Tadokoro, 2018), and lower SPRED1 expression in acute myeloid leukemia associates with a poor outcome (Li, 2015; Olsson, 2014; Pasmant, 2015), suggesting a potential role of this gene as a tumor suppressor in myeloid malignancies. In CML, however, the role of Spred1 has not been fully dissected. Thus, we generated Spred1 KO CML (i.e., Spred1-/-SCLtTA/BCR-ABL) mice by crossing Spred1 KO (a gift from Dr. Yoshimura, Japan) with inducible SCLtTA/BCR-ABL CML mice. Spred1 KO mice showed increased cell cycling of BM long-term HSCs (LTHSCs; Lin-Sca-1+c-kit+Flt3-CD150+CD48-; G0: 62% vs 76%), and increased white blood cell (WBC) counts [14 vs 5.9 k/ul at 12 weeks (w) old, n=15 per group, p<0.0001], as compared to wt mice. Upon B/A induction by tetracycline withdrawal, Spred1-/-SCLtTA/BCR-ABL mice had higher WBC (102.5 vs 12 k/ul at 4 w, n=15 per group, p<0.0001), more pronounced splenomegaly (spleen weight: 0.28g vs 0.19g, n=4 per group, p=0.06) and a significantly shorter survival (median: 39 vs 83 days, n=23 per group, p<0.0001) than Spred1 wt CML mice. In Spred1-/-SCLtTA/BCR-ABL mice, we observed a more rapid expansion of circulating mature myeloid cells (CD11b+Gr-1+ cells: 63% vs 25%, n=8 per group, p<0.01) and a deeper decrease of BM LTHSCs (1,385 vs 2,164 per femur, n=5 per group, p<0.01) and increase of spleen LTHSCs (27330 vs 18546, n=5 per group, p<0.01) at 4 w after B/A induction compared with Spred1 wt CML mice. Further, we found a higher fraction of Spred-/-SCLtTA/BCR-ABL mice (33% vs 10%) developed lymph node enlargement, with infiltration with pro-B lymphoblastic cells (B220+CD43+CD19+IgM−) compared with Spred1 wt CML mice. Altogether these features suggested that Spred1 insufficiency accelerates CML development and evolution to more aggressive phases of the disease. Since upregulation of Spred1 reportedly disrupts vascular integrity (Fish, 2008; Wang 2008), a finding that we have also confirmed in the BM niche, in order to evaluate separately the leukemogenic effect of Spred1 expression on different compartments of the BM niche, we generated the following conditional Spred1 KO strains: Spred1flox(f)/fMxl-cre+ (Spred1 KO in HSCs, hereafter called Spred1HSCΔ/Δ), Spred1f/fTie2-cre+ [Spred1 KO in endothelial cells (ECs), hereafter called Spred1ECΔ/Δ], Spred1HSCΔ/ΔSCLtTA/BCR-ABL and Spred1ECΔ/ΔSCLtTA/BCR-ABL by crossing SCLtTA/BCR-ABL with the above Spred1 KO mice. LTHSCs from Spred1HSCΔ/ΔSCLtTA/BCR-ABL mice showed an increase in cell cycling, RAS/MAPK/ERK activity and Bcl-2 levels, and higher engraftment in recipient mice (blood: 9.7% vs 26.5% at 6w, 14.8% vs 42% at 8w, 14.7% vs 48% at 12w, n=10 per group, p<0.01), compared to Spred1 wt CML LTHSCs. Spred1HSCΔ/ΔSCLtTA/BCR-ABL mice (n=15) showed enhanced leukemia progression (WBC: 19 vs 12 k/ul, p=0.004; CD11b+Gr-1+ in blood: 36% vs 25%, p=0.04 at 4 w after B/A induction) and a significantly shorter survival (median: 49.5 vs 83 days, p=0.01) compared to Spred1 wt CML mice (n=20). However, the disease in these mice appeared to be overall less aggressive than global Spred1 KO CML (i.e., Spred1-/-SCLtTA/BCR-ABL) mice (WBC: 19 vs 102 k/ul; CD11b+Gr-1+ in blood: 36 vs 63%; Survival: 49.5 vs 39 days), suggesting that Spred1 depletion in other non-hematopoietic cell compartments may also be important for leukemogenesis. In fact, Spred1ECΔ/ΔSCLtTA/BCR-ABL mice (n=8) showed enhanced leukemia progression (WBC: 26 vs 9.8 k/ul at 4 w after B/A induction, p=0.02), a trend for a reduced survival (median: 56 vs 83 days, p=0.09), and increased arteriolar vascularization, compared to Spred1 wt CML mice (n=20). Mechanistic studies on how endothelial Spred1 insufficiency co-participates in leukemogenesis are ongoing. Altogether our results support a role of Spred1 insufficiency in distinct BM niche compartments to produce a more aggressive CML phenotype, likely through different, but complementary mechanisms. Spred1 may therefore emerge as a novel target for advanced CML. Disclosures No relevant conflicts of interest to declare.
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Medeiros, Larissa A., Samir K. Nabhan, Marco Antonio Bitencourt, et al. "Long-Term Clinical Outcome of Patients with Acquired Aplastic Anemia In Brazil Using Cyclosporine-A (CSA) and Prednisone (PRED): 20 Years Follow-up From a Single Institution." Blood 116, no. 21 (2010): 2234. http://dx.doi.org/10.1182/blood.v116.21.2234.2234.
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Abstract Abstract 2234 Introduction/Background: Immunosuppressive therapy is the best alternative for patients with severe aplastic anemia (SAA) without matched sibling donor or with age > 40 years. Since 1988, an alternative protocol was developed with cyclosporine (CSA) and prednisone (PRED) due to irregularity in distribution of anti-thymocyte globulin (ATG) in Brazil. This study aims to show the results of this treatment on the quality of response, overall survival and development of clonal evolution. Materials and methods: 384 patients diagnosed with SAA (Camitta and Bacigalupo criteria) were evaluable by medical records review from 12/1988 to 12/2008. The immunosuppressive therapy consisted of CSA: 12mg/kg/day BID from day (D)1- D8, then 7mg/kg/day BID until 1 year. After that CSA was progressively tapered (5% each month) and ultimately stopped usually by two years. CSA levels were kept between 200–400ng/ml. PRED: 2mg/kg/day from D1-D14 then 1mg/kg/day from D15- D45. From that day on PRED dose was tapered 20% each week. Sulfamethoxazole-trimethoprim and fluconazole were used for prophylaxis against Pneumocystis jiroveci (P carinni) and fungal diseases, respectively. Treatment response was defined as Table 1. Treatment evaluation was performed at 6 weeks, 3, 6 and 12 months and then yearly. At diagnosis: median age was 21 years (2-75), disease duration 95 days (2-4749), and median number of transfusions were 12 (0-200). Etiology was idiopathic in 78%. In peripheral blood, median hemoglobin was 7.4g/dL, granulocytes 580/uL, platelets 12.000/uL and reticulocyte 0.5% (corrected value). 60% of the patients had not been treated previously. Results: Overall survival was 61% ± 3 with a median follow-up of 7 years (range: 2 months - 23 years). Response to treatment: 51% had some degree of response, with good quality of life and transfusions independent (143 patients with complete response and 53 partial response). 36 patients had no response and there were 96 deaths. Fifty six patients have lost follow-up. Most patients achieved response between 3 and 6 months of therapy. In multivariate analysis the number of neutrophils ≥ 200/uL (p = 0.009), platelets ≥ 12.000/uL (p = 0.018), reticulocyte ≥ 0.5% (p <0.001) and starting treatment after 1997 (p = 0.002) had an impact on overall survival. Patients with 15 or more previous transfusions (p = 0.006) and age ≥ 40 years (p = 0.003) had lower survival. Overall survival was 63% ± 4 and 42% ± 6 for for patients with severe disease and very severe aplastic anemia (p <0.001). The subgroup analysis of patients under 10 years old had similar results. Among patients with response, thirty-four remained dependent of CSA. Cumulative incidence of relapse was 28% ± 4 within a median of 4.4 years. Hypertension, gingival hypertrophy and diabetes mellitus were common, but easily controlled. The rate of clonal evolution among this cohort was 7.81% (16 patients developed Paroxysmal Nocturnal Hemoglobinuria, 9 Myelodysplastic Syndrome and 5 Acute Myeloid Leukemia). Conclusion: This study, with a long follow-up, has demonstrated that the overall survival using CSA and PRED is similar to that reported with ATG therapy. Even patients with partial responses had achieved good quality of life, free from transfusions and infections. Survival was influenced by the neutrophils, platelet counts, reticulocyte, number of transfusions, age at diagnosis, and therapy started after 1997. The incidence of clonal evolution was lower when compared to reported trials with ATG + CSA. Disclosures: Oliveira: Alexion: Speakers Bureau. Funke: Novartis, Bristol: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Pasquini: Novartis, Bristol: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.
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Benevolo, Giulia, Pietro Pioltelli, Michele Spina, et al. "Cerebrospinal Fluid Flow Cytometry Analysis in Newly Diagnosed Aggressive Non-Hodgkin Lymphomas at High Risk for Leptomeningeal Disease: Result of a Multicentric Prospective Italian Study." Blood 114, no. 22 (2009): 2919. http://dx.doi.org/10.1182/blood.v114.22.2919.2919.
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Abstract Abstract 2919 Poster Board II-895 Background: Flow cytometry (FCM) assessment of cerebrospinal fluid (CSF) has recently been known to increase the rate of positivity of occult leptomeningeal disease (LD) in comparison to conventional cytologic examination (CC). However it's still unknown its prognostic value. Patients and methods: The aim of this study was to compare CC vs FCM in a large cohort of patients with newly diagnosed aggressive NHL at high risk for LD (diffuse large B-cell lymphoma (DLBCL) IPI 2-3 and elevated LDH with at least two extranodal sites or with bone marrow, testis, paranasal sinuses, orbit or paravertebral involvement; Burkitt lymphoma (BL); blastoid variant of mantle cell lymphoma (B-MCL); B-cell precursor lymphoblastic lymphoma (B-LL); HIV+ aggressive lymphoma patients). All patients were required to have no evidence or signs of neurological disease. All patients received intrathecal standard prophylactic therapy with 12 mg of methothrexate except for BL that were given prophylaxis with 50 mg of liposomial aracytin for a total of 4 doses. CFS samples were analysed both with CC and FCM. The incidence of positive test for occult LD with FCM and CC was compared using the McNemar test for paired data. Results: Between August 2004 and June 2008, a total of 159 consecutive patients were enrolled in 11 Italian centres and underwent evaluation of CSF. Out of these, 128 patients (80%) were considered at high risk of occult LD. Clinical characteristics were: median age 53 years (IQR:43-62); DLBCL 96 patients (75%); BL 21 pts (16%); B-MCL 6 pts (5%); B-LL 5 pts (4%); 26 pts (20%) were HIV positive. FCM was able to detect a clonal population in 17 out of 128 patients (13%) whereas CC detected abnormal cells only among 7 pts (5%)(p= 0.0002). Therefore, 10 patients (8%) were discordant: FCM+/CC-. Among the 128 patients, there was no association between the CFS total protein, glucose level and the presence of positive analysis of FCM, whereas the difference between the number of WBC cells in CSF was significantly higher in patients with positive versus negative FCM with a median value of 12 cells/ul (IQR: 3.5;40) versus 1.0 cells/ul (IQR: 0.0;3.0) (p=0.0120). Univariate and multivariate analyses, using logistic models, showed that abnormal LDH (OR 3.98, 95%CI: 1-15.92)(p=0.05) and number of WBC cells in CSF ≥5 (OR 4.57, 95%CI:1.37-15.33)(p=0.014) were the only predictive factors of a positive test performed by FCM. From date of diagnosis, overall median follow up of survivors was 14 months (IQR:8-22). We observed 39 (30%) systemic progressions, 6 (5%) CNS progressions (in 5 cases an isolated CNS progression whereas 1 pts experienced a CNS along with systemic progression). Thirty-two (25%) patients died and causes of deaths were as follows: 27 progressive disease, 1 infection, 1 treatment related toxicity, 1 hepatitis, 2 unknown. PFS at 1 year was 71% (95%CI:62-78) in the whole group of patients. The progression risk was significantly higher in patients both FCM+/CC+ compared with patients both FCM-/CC- (1-yr PFS 43% vs 74%) (HR 3.8 95%CI:1.6-9.0) (p=0.003). An higher but not significant risk of progression was found in pts discordant (FCM+/CC-) with respect to patients both FCM-/CC- (1-yr PFS 65% vs 74%) (HR 1.61, 95%CI:0.63-4.11) (p=0.315). In the univariate and multivariate analyses performed with Cox models, we found that the presence of ECOG PS≥2 (HR 2.14, 95%CI: 1.14-4)(p=0.018) and level of protein in CSF >40/ul (HR 1.83 95%CI: 1.01-3.29)(p=0.045) were prognostic factor of PFS. Conclusion: FCM assessment of CSF increase the rate of positivity of occult LD compare with CC but it's clinical relevance is still to be clearly defined. Our preliminary data suggest that patients both FCM+/CC+ have an higher risk of progression compared with those both negative, whereas discordant cases may have an intermediate prognosis. Disclosures: No relevant conflicts of interest to declare.
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Beltran, Brady E., Erick Cotacallapa, and Jorge J. Castillo. "Survival and Clinicopathological Characteristics of EBV-Positive Diffuse Large B-Cell Lymphoma." Blood 120, no. 21 (2012): 1588. http://dx.doi.org/10.1182/blood.v120.21.1588.1588.
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Abstract Abstract 1588 Background: EBV-positive diffuse large B-cell lymphoma (EBV+ DLBCL) of the elderly is a provisional entity included in the 2008 WHO Classification of Lymphomas. Diagnostic criteria include age >50 years, DLBCL morphology and EBV expression in lymphomatous cells. However, these criteria are evolving as several patients are <50 years and a specific cut-off for the percentage of EBV expression has not been defined. The goal of this retrospective study is to evaluate clinical and pathological characteristics of EBV+ DLBCL from Peruvian patients. Methods: Between January 2002 and January 2012, all patients meeting criteria for EBV+ DLBCL were included in the analysis. Patients with evidence of immunosuppression were excluded. All cases re positive for the presence of EBV-encoded RNA (EBER) by in situ hybridization, and CD20 and/or PAX-5 expression by immuno-histochemistry. Clinical data were reviewed retrospectively and patient's biopsies were analyzed for the expression of BCL6, CD10, CD30 and MUM-1/IRF4 using a tissue microarray (TMA) technique. The overall survival (OS) curves were calculated using the Kaplan-Meier method, and compared using the log-rank test. Results: A total of 43 EBV+ DLBCL patients are included in this study. The median age was 73 years (range 25–95 years). Four patients (9% ) were <50 years. The male:female ratio was 2.2:1. B symptoms occurred in 59%, ECOG >21 in 60%, advanced stage (III/IV) in 58%, elevated LDH levels in 44%, and lymphocyte count <1000/uL in 35%. The International Prognostic Index (IPI) score was 0–2 in 39% and 3–5 in 61% of the patients. Extranodal disease occurred in 20 patients (46%): stomach (n=3), tonsil (n=3), pleura (n=2), palate (n=2), cecum (n=2), bone marrow (n=2), ileum (n=1), bone (n=1), skin (n=1), lung (n=1), meninges (n=1), breast (n=1) and peritoneum (n=1). Three patients had central nervous system involvement (7%), one at presentation and two at relapse. Based on the Hans classification, 76% had non-germinal center profile. Ki67 expression was >80% in 53% of the patients. Eleven evaluated patients had a c-myc-negative status. Chemotherapy was received in 75% of the cases due to poor performance status. The overall response rate with conventional chemotherapy was 46%, with complete response in 39%, partial response in 7%, and no response in 54%. The median survival was 7.5 months. The Oyama score was: 0 factors (13%), 1 factor (47%), and 2 factors (40%) with median OS of 41, 11 and 1.5 months respectively (p=0.07). A lymphocyte count <1000/uL was a prognostic factor for OS (p=0.001). Conclusions: Based on our study, which is the largest cohort in Latin-America, EBV+ DLBCL is an aggressive entity with frequent extranodal disease and poor response to conventional chemotherapy. The overall survival remains poor. Lymphopenia, as defined as lymphocyte count <1000/uL, appears as a prognostic factor for OS. Disclosures: No relevant conflicts of interest to declare.
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Blum, William, Rebecca B. Klisovic, Alison Walker, et al. "Epigenetic Targeting Via Transcriptional Inhibition of DNA Methyltransferase: a Phase I Study of Bortezomib in Combination with 5-Azacytidine in Adults with Relapsed or Refractory Acute Myeloid Leukemia (AML)." Blood 114, no. 22 (2009): 2065. http://dx.doi.org/10.1182/blood.v114.22.2065.2065.
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Abstract Abstract 2065 Poster Board II-42 Background: Hypomethylating agents have significant clinical activity in myelodysplastic syndromes (MDS) and AML. In AML, we recently demonstrated a novel epigenetic mechanism of action for the proteasome inhibitor bortezomib (Liu, Blood 2008). Bortezomib induced hypomethylation of leukemic cells in vitro and in vivo via depletion of the Sp1/NF-kB transcriptional activation complex on the DNA methyltransferase 1 (DNMT1) gene promoter, which results in down-regulation of DNMT1 mRNA and enzyme, DNA hypomethylation and re-expression of otherwise hypermethylated target genes. Based on this preclinical work, we designed a phase I dose escalation study of 5-azacytidine (AZA) in combination with bortezomib in AML. Methods: Adults with relapsed or refractory AML by WHO criteria and preserved organ function with ECOG ≤2 were eligible. Previous decitabine or AZA was permitted. Patients received AZA at 75mg/m2 IV daily for days (d) 1-7. Bortezomib was gradually dose escalated–dose level 1 (DL 1): 0.7mg/m2 by IV push given immediately after AZA on d 2 and 5; DL 2: 0.7mg/m2 on d 2, 5, 9, and 12; DL 3: 1.0mg/m2 on d 2, 5, 9, and 12; and DL 4: 1.3mg/m2 on d 2, 5, 9, and 12. Cycles were repeated every 28 d, regardless of count recovery or response at least until 3 cycles were administered. Responses were graded by International Working Group criteria for AML (Cheson, JCO 2003). Bortezomib was discontinued after 3 cycles if no objective response of complete remission (CR), CR with incomplete count recovery (CRi), or partial remission (PR) was achieved, but AZA could be continued beyond this timepoint in the absence of disease progression. For responding patients, 12 or more cycles of therapy were permitted. Dose limiting toxicities (DLT) were assigned for cycle 1 of therapy. Given the high likelihood of infection in this population regardless of therapy, infection was not considered a DLT. Six additional patients were treated at the recommended phase 2 dose (RP2D). Results: 23 patients were enrolled with a median age of 65 years (range, 42-81) and had received a median of 2 prior inductions (range, 1-5). Median presenting WBC was 3,700/uL (500-59,100/uL); median BM blast was 26% (2-93%). 14 patients were refractory to last therapy received, including 4 with primary refractory AML. 9 patients had relapsed disease; all but 2 of these had prior CR duration <1 year. Patients received a median of 2 cycles of study therapy (range, 1-12+ cycles). Dose escalation was halted once the target bortezomib dose was reached; the RP2D was AZA at 75mg/m2 d 1-7 plus bortezomib 1.3mg/m2 d, 2, 5, 9, 12. Though no toxicities were considered to be DLT in this study, infection and/or febrile neutropenia were universal. Death within 8 weeks occurred in 5 patients (22%) due to pneumonia (1), sepsis (1), or progressive disease (3). Two patients had discontinuation of bortezomib after 2 cycles due to Grade 3 neuropathy; only 1 patient received bortezomib beyond 3 cycles. In 3 patients without objective response (and with no progression), AZA alone was continued after 3 cycles of combination therapy; each reported a subjective improvement in fatigue without bortezomib. Overall, the objective response rate was 26% (6/23). Responses were as follows: 3- CR, 2- CRi, and 1-PR. One CRi patient (in cytogenetic remission also) who discontinued study treatment after 2 cycles due to unrelated trauma subsequently had complete count recovery, but a repeat marrow examination was not performed. Three patients went on to allogeneic transplantation due to response achieved. Response followed the typical pattern of azanucleoside activity, requiring more than one cycle of therapy; the median number of cycles to initial response was 2 (range, 1-5). 5/6 responders had response to combination therapy; one patient responded following 5 cycles of treatment, the last 2 cycles with AZA as a single agent. Conclusions: The combination of 5-azacytidine and bortezomib is well tolerated and active in this cohort of relapsed or refractory AML patients. Additional studies to further elucidate the role of proteasome inhibition as a mediator of hypomethylating activity in AML are warranted. Correlatives studies are ongoing. Disclosures: Blum: Celgene: Research Funding.
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Ohinata, Aki, Michael J. Wallace, Michael J. Overman, Jonathan Phillips, Robert A. Wolff, and Cathy Eng. "The role of partial splenic embolization (PSE) in the management of chemotherapy-induced thrombocytopenia." Journal of Clinical Oncology 30, no. 4_suppl (2012): 569. http://dx.doi.org/10.1200/jco.2012.30.4_suppl.569.
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569 Background: Chemotherapy-induced splenomegaly is a relatively known treatment complication, where the clinical sequale of hypersplenism is persistent thrombocytopenia due to splenic sequestration. For cancer patients (pts) undergoing chemotherapy, thrombocytopenia may result in a dose delay or dose reduction, thus reducing dose intensity. The impact of refinement in technique with limited volume embolization (50-70%) of the spleen upon morbidity and mortality has not been well studied. Methods: A retrospective review of gastrointestinal cancer pts undergoing PSE for thrombocytopenia to facilitate the initiation or resumption of systemic chemotherapy between Jan. 2008 and March 2011 was completed. Pre- and post-PSE platelet (plt) counts within 30 days were evaluated for benefit of treatment. Objectives included the re-initiation of systemic therapy and post-PSE plt count >150 (< 30 days). Periprocedural laboratory values and adverse events were recorded. Results: PSE was performed in 79 pts. Median prior chemotherapy regimens = 2 (range 1-3). The median follow-up was 12M (range: 7-31). The mean plt count prior to PSE was 80 K/ UL (3-196). Post-PSE platelet count of > 150 was achieved in 52 (66%) pts with a mean peak plt count of 219 K/UL. Six (8%) pts underwent repeat PSE due to recurrent thrombocytopenia after initiation of systemic therapy. Re-initiation of chemotherapy was achieved in 59 (79%) pts. The median duration of chemotherapy following PSE was 8M (95% CI: 4.2-14.2); median overall survival was 33M (95% CI: 10-47). Post-procedure fever developed in 7 (9%) pts and pleural effusion, atelectasis, or consolidation was reported in 8 (10%) pts. Seventeen (21%) pts developed reversible grade 1 hyperbilirubinemia. Median length of hospital stay was 3 days (interquartile range 1-5 days). 60-day mortality rate was 9% (7 of 79). Conclusions: Partial splenic embolization (PSE) is a safe and effective method of managing thrombocytopenia secondary to chemotherapy-induced hypersplenism to facilitate re-initiation of systemic therapy in cancer patients. PSE may be considered as a potential option in patients with good performance status to facilitate further systemic chemotherapy.
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Beltran, Brady E., Julio C. Chavez, Eduardo M. Sotomayor, and Jorge J. Castillo. "Lymphopenia Is an Adverse Prognostic Factor in EBV-Positive Diffuse Large B-Cell Lymphoma." Blood 124, no. 21 (2014): 5408. http://dx.doi.org/10.1182/blood.v124.21.5408.5408.
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Abstract Background: EBV-positive diffuse large B-cell lymphoma (EBV+ DLBCL) of the elderly is a provisional entity included in the 2008 WHO Classification of Lymphomas. Diagnostic criteria include age >50 years, DLBCL morphology and EBV expression in lymphomatous cells. However, these criteria are evolving as several patients younger than 50 years of age without immunodeficiency have been diagnosed. Also, a specific cut-off for the percentage of EBV expression has not been defined. Lymphopenia, monocytosis, neutrophil-to-lymphocyte ratio (NLR) and the lymphocyte-to-monocyte ratio (LMR) have been reported prognostic in patients with DLBCL and other lymphomas. The goal of this retrospective study is to evaluate these novel prognostic factors in a cohort of EBV+ DLBCL patients. Methods: Between January 2002 and January 2014, all patients meeting criteria for EBV+ DLBCL were included in the analysis. Patients with evidence of immunosuppression were excluded. All cases were positive for the presence of EBV-encoded RNA (EBER) by in situ hybridization, and CD20 and/or PAX-5 expression by immunohistochemistry. Clinical and pathological data were reviewed retrospectively. Lymphopenia was defined as an absolute lymphocyte count <1000/uL, and monocytosis as an absolute monocyte count >600/uL. NLR was defined as the division of the absolute neutrophil count over the absolute lymphocyte count. LMR was defined as the division of the absolute lymphocyte count over the absolute monocyte count. Patient's biopsies were analyzed for the expression of BCL6, CD10, CD30 and MUM-1/IRF4. Overall survival (OS) curves were calculated using the Kaplan-Meier method, and compared using the log-rank test. Results: A total of 45 EBV+ DLBCL patients are included in this study. The median age was 68.9 years (range 25-95 years). Four patients (9%) were younger than 50 years. The male:female ratio was 2.2:1. B symptoms occurred in 60%, ECOG >1 in 55%, advanced stage (III/IV) in 58%, and elevated LDH levels in 44%. The International Prognostic Index (IPI) score was 0-2 in 39% and 3-5 in 61% of the patients. Lymphopenia was seen in 35%, and monocytosis in 69% of patients. Extranodal disease occurred in 23 patients (51%): stomach (n=3), tonsil (n=3), pleura (n=2), palate (n=2), cecum (n=2), bone marrow (n=2), ileum (n=1), bone (n=1), skin (n=1), lung (n=1), meninges (n=1), soft tisue (n=1) and peritoneum (n=1). Based on the Hans classification, 76% had non-germinal center origin. Ki67 expression was >80% in 53% of the patients. Chemotherapy was not received in 25% of the cases due to poor performance status. The Oyama score was: 0 factors (13%), 1 factor (47%), and 2 factors (40%) with 2-year OS of 86%, 49% and 27%, respectively (p=0.016). Lymphopenia was an adverse prognostic factor for OS (HR 3.23, 95% CI 1.24-8.43; p=0.017) in the univariate analysis. The 2-year OS for EBV+ DLBCL patients with lymphopenia was 24%, and 55% for patients without lymphopenia. Monocytosis, NLR and LMR were not significantly associated with OS in our cohort of EBV+ DLBCL patients. Conclusions: Lymphopenia, defined as an absolute lymphocyte count <1000/uL, appears as a prognostic factor for OS in EBV+ DLBCL. Disclosures No relevant conflicts of interest to declare.
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Awan, Farrukh, David Deremer, Elaine Mebel, Samith Thomas Kochuparambil, and Anand P. Jillella. "Utility of Plerixafor In Addition to Chemotherapy and G-CSF Mobilization Regimens." Blood 116, no. 21 (2010): 4443. http://dx.doi.org/10.1182/blood.v116.21.4443.4443.
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Abstract Abstract 4443 Introduction: Various chemotherapeutic agents particularly cyclophosphamide (CY) are utilized in combination with growth factors in an attempt to increase the number of stem cells available for collection in the peripheral blood. Plerixafor (P) is a reversible antagonist of CXCR4 and interrupts its interaction with SDF-1. This results in a rapid release of hematopoietic stem cells from the marrow to the circulation. Recent pivotal phase III trial data has established the efficacy of P in combination with G-CSF (G) in patients who had failed prior attempts at stem cell collection. However, there is limited data about the utility of plerixafor in patients who are being mobilized with chemotherapy and G. Method: In this single institution study of uniformly treated patients we describe our experience with the use of P as a salvage option in patients who fail to optimally mobilize CD34+ cells (>5 × 106 CD34+ cells/kg). Patients received CY (3-4 g/m2) followed by GCSF (10 mcg/kg) from day 1 to day 10. Thirteen patients (6 NHL, 4 MM, 2 Hodgkin lymphoma, 1 Ewings sarcoma) received salvage P from 2008–2010. Their outcomes were compared with 10 matched, historic controls mobilized with (CY n=8; CY + etoposide n=1; CY + topotecan n=1) plus G-CSF (10mcg/kg/d) identified from our institutional database. Data was collected on mobilization and transplant outcomes and analyzed utilizing SPSS version 13.0. Patients receiving P were closely matched to historic controls (CY+G). Result: Both groups were similar with regards to age, gender, disease type, prior therapies and performance status (p>0.05 for all). Patients in the P arm received a median of 2.5 doses (range 1–8). The mean CD34+ count was 21.5cells/ul in the P arm and 32.5 cells/ul in the CY+G arm (p=0.2). Similarly, no significant difference was observed in the average number of apheresis sessions in the P vs. CY+G arms (4.2 vs. 4.4, p=0.8) or the total number of CD34+ stem cells collected (4.0×106/kg vs. 3.9×106/kg, p=0.9). However, 7 out of the 13 patients who received P did have an increase of >10 CD34+ cells/ul in their peripheral blood. Utilizing a cut-off of 5×106 CD34+/kg, 3 (23%) patients in the P arm and 3 (30%) patients in the CY+G arm had a successful harvest. Three NHL patients required >4 doses of P, but all eventually collected >2 × 106 CD34+ cells/kg. Neutrophil and platelet engraftment dynamics were similar in both groups of patients. Median time to neutrophil engraftment was 10 days for both groups, p=0.8, and to platelet engraftment was 22 days vs. 20.5 days, p=0.1, respectively for P vs. CY+G. Conclusion: Our limited single-center retrospective case-controlled outcomes data, suggests that when compared with CY+G, the addition of P as a salvage agent does not significantly improve mobilization outcomes. Further evaluation is needed to combine P with CY+G in terms of optimal timing and potentially dosing of chemotherapy agents utilized. We suggest that the combination P+G would provide better potential outcomes such as improved collection and less hospitalization and reduce the use of chemo-mobilization prior to an Autologous Hematopoietic Stem Cell Transplant. Disclosures: No relevant conflicts of interest to declare.
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Kowalewski, Alexander R., John N. Rogers, James R. Crum, and Jeffrey C. Dunne. "Sand Topdressing Applications Improve Shear Strength and Turfgrass Density on Trafficked Athletic Fields." HortTechnology 20, no. 5 (2010): 867–72. http://dx.doi.org/10.21273/horttech.20.5.867.
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Drain tile installation into a native-soil athletic field and subsequent sand topdressing applications are cost-effective alternatives to complete field renovation. However, if cumulative topdressing rates exceed root system development, surface stability may be compromised. The objective of this research was to evaluate the effects of cumulative topdressing, over a compacted sandy loam soil, on the fall wear tolerance and surface shear strength of a kentucky bluegrass (Poa pratensis)–perennial ryegrass (Lolium perenne) stand. Research was initiated in East Lansing, MI, on 10 Apr. 2007. A well-graded, high-sand-content root zone (90.0% sand, 7.0% silt, and 3.0% clay) was topdressed at a 0.25-inch depth [2.0 lb/ft2 (dry weight)] per application, providing cumulative topdressing depths of 0.0, 0.5, 1.0, 1.5, or 2.0 inches applied from 11 July to 15 Aug. 2007. Fall traffic was applied twice weekly to all treatments from 10 Oct. to 3 Nov. 2007. In 2008, topdressing applications and traffic, as described earlier, were repeated on the same experimental plots. Results obtained from this research suggest that the 0.5-inch topdressing depth applied over a 5-week period in the summer will provide improved shoot density and surface shear strength in the subsequent fall. Results also suggest that topdressing rates as thick as 4.0 inches accumulated over a 2-year period will provide increased shoot density, but diminished surface shear strength.
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Kim, Yeo-Kyeoung, Se Ryeon Lee, Yong Park, et al. "Efficacy Of Ruxolitinib In Korean Myelofibrosis Patients and Cases Complicated TB Lymphadenitis During The Treatment." Blood 122, no. 21 (2013): 1596. http://dx.doi.org/10.1182/blood.v122.21.1596.1596.
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Abstract Introduction Ruxolitinib is a selective JAK 1/2 inhibitor, which shows an excellent treatment outcome in myelofibrosis (MF) patients. Main side effect of JAK 1/2 inhibitors is an increased risk of infection. JAK1/2 inhibition may interfere with the differentiation of interferon-γ (IFN-γ) producing Th1 cells and IFN-γ is a key cytokine involved in protective immunity against Mycobacterium tuberculosis(TB). During COMPORT-II trial, a case of disseminated TB with ruxolitinib was reported. Here, we analyze the efficacy and safety of ruxolitinib in Korean MF patients and report cases of TB lymphadenitis during the treatment. Methods Forty-nine patients diagnosed with PMF, PPV-MF or PET-MF have been enrolled and at this time twenty patients are evaluable (median age; 63 years, 37-80). Starting dose of ruxolitinib was determined based on each patient’s baseline platelet count (20 mg bid/d for a baseline platelet more than 200,000/µL, 15 mg bid/d for 100,000-200,000/uL). To determine the efficacy of ruxolitinib, we serially assessed the spleen size by palpation, myelofibrosis symptom assessment using MFSAF and BM examination with JAK2V617Fmutation allele burden. Among 20 evaluable patients, 16 assessed IFN-γ release assays (IGRAs, quantiFERON-TB Gold test) before starting ruxolitinib. Results Of total twenty patients, 12 (60.0%), 3 (15.0%) and 5 (25.0%) were PMF, PPV-MF and PET-MF, respectively. By DIPSS, 13 (65.0%) was Int-2 risk, 3 (15.0%) and 4 (20.0%) were Int-1 and high risk. Eleven patients started with 20 mg bid/d (median baseline platelet: 302,000/uL, 206,000-814,000) and nine were 15 mg bid/d (median; 139,000/uL, 100,000-194,000). Median baseline total symptom score (TSS) was 12 (1-36) and palpable spleen length was 19 cm (1-30). JAK2V617Fmutation was positive in 13 (65.0%) patients (median allele burden; 87.1%, 26.2-93.7). Median time of ruxolitinib exposure was 2.0 ms. (0.8-6.2). Two patients increased TSS following ruxolitinib treatment, however, median maximal reduction in TSS was above 90.9% (27.8-100) and 64.7% of patients showed more than 50% reduction of TSS with ruxolitinib. In an aspect of spleen length, all except two patients showed decreased palpable spleen length. Median maximal reduction in spleen length was 70.2% (0-100) and 72.2% of patients showed more than 35% reduction in spleen length with ruxolitinib. Three patients (15.0%) experienced gr. 3/4 thrombocytopenia and one (5.0%) gr. 3 neutropenia. Among patients who assessed pre-treatment IGRAs, only one revealed positive IGRAs. Since there was no evidence of active TB in symptom and radiologic examination, he was diagnosed as latent TB infection (LTBI) and started 9 ms.-isoniazid (INH) treatment. He had a huge hepatosplenomegaly combined with large amount of ascites which needed frequent paracentesis, hence, we started ruxolitinib with INH treatment. He showed no evidence of active TB and achieved negative IGRAs result on 5 ms. of ruxolitinib treatment. On 1 m. and 5 ms. of ruxolirinib treatment, two patients developed pyrexia and neck masses which were diagnosed as TB lymphadenitis. All of them had no previous history of TB and showed negative results in pre-treatment IGRAs and radiologic examinations. First patient discontinued ruxolitinib by herself and eventually died of MF progression 2 ms. later. Second patient continued ruxolitinib treatment with TB medication and there was no evidence of active TB or MF progression on 5 ms. of ruxolitinib treatment. Conclusions Ruxolitinib was generally well tolerated and showed an excellent treatment outcome in Korean MF patients. By 2008 WHO report, intermediate burden of TB cases exist in Korea, hence, TB is still endemic in Korea. According to 2011 Korean Guidelines for TB, LTBI should be treated in patients receiving immunosupressive agents including TNF-α inhibitors. Although further prospective investigations on the incidence of TB with JAK 1/2 inhibitors in TB endemic countries are warranted, it seems to be reasonable to check the possibility of LTBI before starting JAK 1/2 inhibitors. LTBI confirmed patients receiving JAK 1/2 inhibitors may be deemed a high risk of active TB and consider LTBI treatment. Furthermore, it is necessary to use a caution for active TB infection during the treatment of JAK 1/2 inhibitors in such countries. Disclosures: No relevant conflicts of interest to declare.
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Cai, Yuli, Chao Liu, Ye Guo, et al. "Analysis of 48 Cases Pediatric Chronic Myeloid Leukemia from China: Results from a Single Institute in China." Blood 134, Supplement_1 (2019): 5911. http://dx.doi.org/10.1182/blood-2019-125565.
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Objective: Chronic myeloid leukemia (CML) is a rare disease among children. It comprises 3% of childhood leukemias. CML in children is different from CML in adult. Here we analyzed the clinical features and prognosis of pediatric CML in a single institute from China. Methods: A retrospective study was performed by reviewing clinical records of pediatric CML from 2002 to 2019. Results: A total of 48 pediatric CML cases were included in the study, with 35 males and 13 females (M: F=2.7:1). Four cases were diagnosed during 2002~2007, 12 cases during 2008~2013 and 32 cases during 2014~2019. Two (4.2%) patients were in accelerate phase (AP) and other 46 patients were in chronic phase (CP) at diagnosis. Median age of onset was 9y (range 1~17y). The most common symptoms were fever (21.6%), fatigue (14.9%) and cough (10.8%). Median size of spleen under left costal margin was 5cm (range 0~21cm). Median WBC count was 15.7/ul, hemoglobin 9.5g/dL, platelet count 58/ul, neutrophils percentage 56% (range 21~74%), basophils percentage 3% (range 1~16%) and median eosinophil percentage was 2% (range 0~19%). Thirty-five patients had done karyotype examination, and 28 cases (80%) with classical Philadelphia chromosome (Ph+). Other 13 patients without Ph chromosome but with BCR/ABL1 fusion gene. In our study, there were 4 patients treated by hydroxyurea and α-interferon, other 44 patients have been used imatinib (IM) 240-340mg/m2 per day. Median time from onset to diagnosis was 0.7 months (range 1 day~12 months). Median follow-up time was 52 months (range 1~200 months), while the 5-year overall survival (OS) and event-free survival (EFS) are 100% and 89.1%, respectively. Different gender, age at diagnosis, WBC count, platelet count, karyotype show no difference in OS and EFS. Four patients suffered from blast crisis (BC) (2 patients progressed after using hydroxyurea for 1 and 33 months, 2 patients progressed after using IM for 36 and 6 months, respectively). One patient's BCR/ABL1 transcript level was increased in 36 months after first administration of IM and recovered at 48 months by adding IM dosage from 200mg to 300mg per day. According to the European LeukemiaNet (ELN) criteria, 95.5% patients achieved complete hematologic response (CHR), 90.5% patients achieved complete cytogenetic response (CCyR) and 66.7% patients achieved major molecular response (MMR) at 3, 12, 18 months after IM administration, respectively. There was obvious correlation between WBC count at diagnosis and early molecular response (EMR). Median WBC count was 4.8/ul in patients with EMR and 38.1/ul in patients without EMR. Other clinical features, such as gender, age at diagnosis, hemoglobin count, platelet count and size of spleen, make no difference in EMR. Conclusion: This is a retrospective study on pediatric CML. The median age at diagnosis is 9 years old. Most of all patients are CML-CP. 5y OS and EFS are 100% and 89.1%. The CHR, CCyR, MMR at 3,12,18 months after IM therapy are 95.5%, 90.5% and 66.7% separately. Until now there is no sufficient data on efficiency and safety specific to pediatric CML patients. Further clinical investigations through international collaboration are need to help more and more patients to achieve treatment-free remission. Disclosures No relevant conflicts of interest to declare.
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Grace, Rachael F., Carolyn M. Bennett, A. Kim Ritchey, et al. "Response to Steroids Predicts Response to Rituximab In Pediatric Chronic Immune Thrombocytopenia." Blood 116, no. 21 (2010): 3681. http://dx.doi.org/10.1182/blood.v116.21.3681.3681.
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Abstract Abstract 3681 Background: Pediatric Immune Thrombocytopenia (ITP) has an incidence of 4–6/100,000 with 1/3 of cases becoming chronic. Treatment choice is arbitrary, because few studies are powered to identify predictors of therapy response. Increasingly, rituximab is becoming a treatment of choice in those refractory to other therapies (Neunert CE, et al. Pediatr Blood Cancer 2008; 51(4):513). Previous studies in ITP have not examined predictors of response to rituximab or whether response to prior treatments predicts response. Objective: To evaluate univariate and multivariable predictors of platelet count response to rituximab. Methods: After local IRB approval, 550 patients with chronic ITP enrolled in the longitudinal, North American Chronic ITP Registry (NACIR) between January 2004 and June 2010. Eligibility included: ages 6 months-18 years at ITP diagnosis, clinical diagnosis of ITP, and ITP duration >6 months. Primary ITP was defined as isolated thrombocytopenia without associated conditions. Secondary ITP included those patients with immune thrombocytopenia associated with other immune-mediated medical conditions, including Evans Syndrome. Treatment response was defined as a post-treatment platelet count ≥50,000/uL within 16 weeks of rituximab and within 14 days of steroids. Steroids were prescribed as 1–4 mg/kg prednisone or adult equivalent over 4–14 days with or without taper. The NACIR captured treatment responses both retrospectively prior to enrollment and then prospectively, and both periods were included in this analysis. The multivariable logistic regression modeling process utilized SAS 9.1 using binary variables which were either significant in the univariate analysis or clinically important. A backwards elimination procedure was used to select the final model. Results: Seventy-six (13.8%) patients were treated with rituximab. Demographics of the patients treated with rituximab include: 42% male; 81% Caucasian, 17% Black, and 2% Asian. The mean age at diagnosis of ITP was 8.4 ± SD 5.1 years. The median platelet count at diagnosis of acute ITP was 10,000/uL (IQR 5,000-20,000/uL). 19 (25%) patients had secondary ITP or Evans syndrome. Treatment with rituximab had an overall response rate of 63.2% (48/76). Univariate predictors of response to rituximab are shown in Table I. The strongest univariate predictor of response to rituximab was response to steroids. Gender, ethnicity, and race were not predictive of response to rituximab. Furthermore, other variables which did not predict rituximab response include: history of a bleeding score ≥3 (Buchanan and Adix, J Pediatr 2002; 141: 683), symptoms ≥1 month prior to ITP diagnosis, older age (age >5 years), platelets ≥20,000/uL at acute ITP diagnosis, and a positive ANA. In multivariable analysis, response to steroids remained a strong predictor of response to rituximab with an OR 6.2 (95% CI 1.8–21.3, p=0.004). Secondary ITP also remained a strong a predictor of a positive response to rituximab with an OR 5.9 (95% CI 1.2–33.3, p=0.03). Conclusion: In the NACIR, response to steroids and secondary ITP were strong predictors of response to rituximab, a finding not previously reported in children or adults. Although this finding requires further validation, this result may provide evidence that rituximab should be most considered in patients previously responsive to steroids. Disclosures: Off Label Use: Rituximab for chronic ITP. Lambert:Cangene: Membership on an entity's Board of Directors or advisory committees. Klaassen:Novartis: Research Funding; Cangene: Research Funding. Neufeld:Novartis, Inc: Research Funding.
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Pomares, Helena, Isabel Sánchez-Ortega, Esther Alonso, et al. "Validation of the Low Risk Prognostic Scoring System (LR-PSS) in Patients with VERY Low, Low and Intermediate Risk IPSS-R Myelodysplastic Syndrome. Results from a Single Center." Blood 126, no. 23 (2015): 2902. http://dx.doi.org/10.1182/blood.v126.23.2902.2902.
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Abstract Background: Myelodysplastic syndrome (MDS) therapeutic decisions have been traditionally based on the IPSS; however, this score system does not allow the identification of patients with low risk disease (low or intermediate-1 IPSS) but a poor prognosis, who could benefit from an early intervention. Garcia-Manero et al (Leukemia 2008) described a specific prognostic scoring system for this subgroup of patients (LR-PSS) based on age ≥60 years, hemoglobin <10g/dl, platelet count <50k/uL or 50-200k/uL, bone marrow blasts ≥4% and unfavorable cytogenetics (non-del(5q), non-diploid). This LR-PSS score system enables the stratification of low risk MDS patients into 3 different risk categories; interestingly, the third category identifies a subgroup of patients with a median overall survival (OS) similar to that of patients classified as intermediate-2 and high risk IPSS. Besides, the IPSS-R described by Greenberg et al (Blood 2012) has demonstrated a strong prognostic value for OS and LFS as compared to the IPSS when applied to different independent series of MDS patients. The prognostic impact of the LR-PSS has not been analyzed in MDS patients with very low-, low- and intermediate IPSS-R scores. Aim: To analyze the prognostic impact according to OS and leukemia free survival of the LR-PSS when applied to a population MDS patients with very low, low and intermediate IPSS-R. Methods: A total of 789 consecutive patients diagnosed with MDS (01/1992-12/2014) at the Catalan Institute of Oncology of Barcelona were included in the study. 413 (52%) had available cytogenetics and therefore, IPSS-R was calculated. Overall, 371 (89%) patients were classified as very low, low and intermediate IPSS-R and included in the study. Results: 123 (30%) patients were classified as very low, 182 (44%) low and 66 (16%) intermediated IPSS-R risk MDS; median age 72 years (range 32-101) and 258 (69%) male. 1.4 % CRDU, 7.6 % RA, 41.6 % RCMD, 16.2 % RAEB‐1, 4.1 % RAEB‐2, 25.9 % CMML and 3.2 % MDS‐U with isolated 5q deletion according to the 2008 WHO classification. At diagnosis, median hemoglobin, platelet and bone marrow blast were 11.8 g/dL (5.5-17.1), 152 x109/L (1-1492) and 3 % (0-17), respectively and fifty-three (14.3 %) patients had unfavorable LR-PSS cytogenetics. For the whole population, median follow up was 6.6 years (range 6-7.7). At the time of last follow up, 48.2 % (179) had died and only 49 (13%) had progressed to acute myeloid leukemia. When the LR-PSS was applied to the very low, low and intermediate IPSS-R subgroups three well-differentiated prognostic categories could be identified: 58 patients (15.6%) category 1, scores 0-2; 277 (74.6%) patients category 2, scores 3-4 and 36 (9.8%) patients category 3, scores 5-7 with significantly different overall survival and leukemia free survival. Median OS for categories 1 (9.4 years; 95% CI 6.7-12), 2 (6 years; 95% CI 5-7.1) and 3 (2.6 years; 95% CI 2.1-3) were significantly different (p<0.001; Figure 1). Moreover, the rate of progression to acute myeloid leukemia was 5% (3/58), 13% (37/277) and 25% (9/36) for categories 1, 2 and 3, respectively. Summary/Conclusion: When applied to a low risk (very low, low and intermediate) IPSS-R cohort of MDS population, the LR-PSS identifies a subgroup of patients with a significantly worse prognosis who could benefit from an early intervention. Further studies are warranted. Fig 1. Kaplan-Meier survival for patients with very low-, low- and intermediate IPSS-R risk assigned to categories 1 to 3 by LR-PSS. Fig 1. Kaplan-Meier survival for patients with very low-, low- and intermediate IPSS-R risk assigned to categories 1 to 3 by LR-PSS. Disclosures Sureda: Takeda: Consultancy, Speakers Bureau.
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Schroeder, Thomas, Christian Saure, Ingmar Bruns, et al. "Clinical Efficacy of Sorafenib in Patients with Acute Myeloid Leukemia (AML) and Activating FLT3-Mutations." Blood 114, no. 22 (2009): 2057. http://dx.doi.org/10.1182/blood.v114.22.2057.2057.
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Abstract Abstract 2057 Poster Board II-34 Introduction: Patients with acute myeloid leukemia (AML) and activating mutations in the Fms-like tyrosine-3 (FLT3) gene have an abysmal prognosis. Together with other groups we have recently demonstrated the clinical activity of the multikinase and FLT3 inhibitor sorafenib in patients with FLT3+ AML (Safaian et al., 2008; Zhang et al., 2008; Metzelder et al., 2009). We here present clinical results of 8 AML FLT3+ patients treated with sorafenib either prior or after allogeneic stem cell transplantation (allo-SCT) on an off-label basis. Patients, Treatment and Response Evaluation: Between February 2007 to August 2009 eight patients with AML (7 female, 1 male, median age: 47 years, range 23-63 years) were treated with sorafenib 800 mg daily (dose range 400-800 mg daily) for a median duration of 37 days (range 5-225 days). Six patients had an internal tandem duplication mutation (ITD), while 2 patients carried a tyrosine kinase domain (TKD) mutation. One patient received sorafenib at diagnosis before remission induction while all other patients had relapsed and/or refractory disease. Response and toxicity were evaluated regularly and defined according to established criteria. Results: Two of four patients who received sorafenib for refractory relapse after allo-SCT (median time to relapse 78 days, range 59-84 days) achieved complete remission (CR) (1 CR, 1 complete molecular remission (CMR) with disappearance of extramedullary chloromas) and survived 164 and 594 days, respectively. One of these patients died after another systemic relapse, while the other died as result of a CNS-chloroma being still in CMR in bone marrow (BM). In the 2 other patients sorafenib induced a hematological response (HR) and these patients survived 188 and 329 days before they died of progressive disease. Of the 4 patients treated prior allo-SCT, 2 had relapsed during consolidation after a previous CR, 1 had refractory disease and 1 was treated at diagnosis. Both patients with relapse showed response to sorafenib treatment thereby permitting allo-SCT. While one achieved HR, the other had regression of multiple isolated cutaneous relapse manifestations. Both patients are still alive at day +81 and day +16 in CMR and CR, respectively. The patient, who was primary refractory to double induction and high-dose cytarabine had a reduction of BM-blasts. She discontinued sorafenib because of neurotoxicity after 13 days. This patient reached a CR after allo-SCT, but died on day + 379 of another relapse. At the time of AML diagnosis the fourth patients had a WBC of 377.000/ul. Despite treatment with hydroxyurea, cytarabine and leukapheresis WBC could not be lowered <100.000/ul within 5 days and the patient developed pulmonary leukostasis syndrome. At this point of time FLT3 TKD mutation was detected and sorafenib was started promptly. Within the next 5 days WBC (peripheral blasts %) declined from 119.700/μl (98%) to 5.300/μl (28%) without tumor lysis syndrome facilitating induction therapy with cytarabine, daunorubicin and etoposide. Sorafenib therapy was continued in parallel and led to a CMR without increased toxicity. In general, sorafenib treatment was well tolerated. Besides neurotoxicity in one patient extrahematological side effects were almost limited to transient dermatological symptoms in two patients, which resolved after discontinuitation of sorafenib. Four Patients developed neutropenia grade IV and thrombopenia grade IV, which was not exclusively attributable to sorafenib, but also to the underlying AML. Conclusion: Our results add to the growing evidence that sorafenib is highly active in patients with FLT3+ AML. In view of the clinical course of our patients we suggest that sorafenib can achieve temporary disease control, but should be integrated into induction and consolidation regimens to achieve curative treatment. Recent data on synergistic effects between sorafenib and cytarabine and the CXCR4 inhibitor AMD3100 suggest these combinations for new clinical trials. Disclosures: Off Label Use: individual treatment approach of patients with refractory FLT3+ AML with multikinase inhibitor sorafenib, which is approved by EMEA + FDA for renal cell carcinoma.
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Wang, Weiwei, Gabrielle Meyers, Haibo Li, Ying Wang, Lisong Shen, and Guang Fan. "Retrospect Reviews of PNH Tests with Long-Term Follow-up in a Single Institution." Blood 134, Supplement_1 (2019): 948. http://dx.doi.org/10.1182/blood-2019-124896.
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I ntroduction : Paroxysmal nocturnal hemoglobinuria (PNH) often presents as hemolysis and/or bone marrow failure. Flow cytometric testing can accurately detect PNH. However, the long term studies on PNH clone size and how it relates to clinical course are few. We sought to understand how PNH clone size correlates with clinical course over time and the impacts on clone size with different treatments. Here we report long term clone size monitoring and clinical data of 57 patients with PNH in a single intuition. Methods : High sensitivity PNH flow cytometry (0.01% limit of detection) was performed with FLAER-FITC, CD64-PE, CD14-ECD, CD15-PC5, CD24-AA7500, CD45-KO for neutrophils & monocytes; CD59-PE and CD235a-AA750 for RBCs. Retrospective analysis was done in the positive PNH cases from 2008-2019 at OHSU. Total 173 cases for 57 patients; including 27 females and 30 males, 52 adults and 5 pediatrics, with a mean age of 45 (range 9-78). We also reviewed results of serum LDH, bone marrow biopsies and molecular/cytogenetics of these patients. Among of these patients, 18 patients (11 females and 7 males, mean age 49.33, age range 29-73) with long term (at least over 4 years) follow-up have more than 3 PNH tests. Besides PNH clone on RBC and PMN, we also reviewed results of WBC count (x103/ul), Hb (g/dL), PLT (x103/ul) serum LDH (U/L), bone marrow biopsy reports and molecular/cytogenetics findings in these patients. Results: Among 57 patients, there are 30 aplastic anemia (AA) patients (53.63%), 7 AA patients progressing to PNH (AA&PNH, 12.28%), 5 myelodysplastic syndromes (MDS, 8.77%), 12 PNH patients (21.05%), 1 pancytopenia, 1 autoimmune disease, 1 thrombosis. The diagnosis of AA and MDS were confirmed by bone marrow biopsy and molecular/cytogenetics. Significantly higher levels of all PNH clones were observed in PNH and AA/ PNH, compared to AA (all P &lt;0.001) and MDS (all P&lt;0.05) shown in Figure A-D. LDH was higher in PNH and AA/PNH than AA and MDS groups (P&lt;0.001, Figure E). LDH demonstrated positive correlation with PNH clone size in RBC-type-III, neutrophils and monocytes (all P&lt;0.0001, R= 0.4447, 0.5469, 0.5711, respectively, Figure F). No correlation was observed between LDH and RBC-type-II. Long term (4-11 years ) follow up include 18 patients were divided into 4 groups: 5 AA treated with immunosuppressant only, 5 AA treated with immunosuppressants and/or eltrombopag, 5 classic PNH or AA that progressed to PNH treated with immunosuppressants and/or eculizumab, and 3 PNH with observation and supplements only. The study showed immunosuppression only has lowest PNH clone size for both RBC and WBC (Figure G-H). As for the Hb and WBC count, there were no statistics differences among 4 groups (Figure I-J). Decreased PLT was detected in eltrombopag group (Figure K). Significantly, increased LDH was observed in the observation/supplement group (Figure L). Interestingly, all these 3 patients without special treatment have high PNH clones and LDH from diagnosis to now over 10 years. Despite receiving basic supportive care, the patients' clinical courses have been stable with only supplementation of vitamin B12 and Folic Acid. Conclusions : Positive PNH test was most frequently seen in AA patients. AA has lower PNH clone size and LDH than those of PNH patients or AA progressed to PNH patients. For all patients, PNH population showed positive correlation with LDH. Our study suggest that it is necessary to follow PNH clone size, as this may impact the decision of when to start therapy with what agents. Figure Disclosures No relevant conflicts of interest to declare.
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Cao, Wenjing, Denise E. Sabatino, Ekaterina Altynova, and X. Long Zheng. "Reconstitution of Recombinant Factor VIII In fVIII-/- mice Restores Von Willebrand Factor Homeostasis." Blood 116, no. 21 (2010): 2213. http://dx.doi.org/10.1182/blood.v116.21.2213.2213.
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Abstract Abstract 2213 Coagulation factor VIII (FVIII) binds von Willebrand factor (VWF) at the D′D3 domain with high affinity. FVIII almost always circulates as a FVIII-VWF complex in blood. Our recent study has demonstrated that FVIII accelerates proteolytic cleavage of VWF by ADAMTS13 under mechanically induced fluid shear stress (Cao et al, PNAS, 2008). In this study, we sought to determine: 1) the domain of FVIII required for the enhancing effect on VWF proteolysis by ADAMTS13 under these conditions; 2) the physiological relevance of this enhancing effect on plasma VWF homeostasis in a murine model. First, we employed the novel vortex-based shear assay developed in the laboratory to assess the rate enhancing effect of various recombinant FVIII variants on VWF proteolysis by ADAMTS13. In these experiments, purified plasma VWF (150 nM) was incubated for 10 min with recombinant ADAMTS13 (50 nM) in the presence of various concentrations of recombinant FVIII variants (0-20 nM) in a total volume of 20 μl under constant fluid shear generated with a bench top mini-vortexer. This maneuver appears to produce ∼75 dyn/cm2 of fluid shear stress. Proteolytic cleavage product (∼350 kDa, the dimer of two C-terminal fragments linked by a disulfide bond) was then determined by 5% SDS-polyacrylamide gel electrophoresis and Western blotting. We showed that addition of a recombinant light chain of FVIII (FVIII-LC) increased the formation of proteolytic cleavage product as a function of increasing FVIII-LC concentrations. This rate enhancing effect was similar to that of full-length recombinant FVIII and B-domainless FVIII (FVIII-SQ). However, addition of a heavy chain of FVIII (FVIII-HC) or a light chain variant lacking the acidic (a3) region (FVIII-Δa3LC) did not increase the formation of cleavage product under the same conditions. These results suggest that FVIII-light chain is sufficient for accelerating VWF proteolysis by ADAMTS13 under physiological conditions. The rate enhancing effect of FVIII-LC depends on its high affinity interaction with VWF. Second, we determined plasma VWF antigen and multimer distribution in fVIII-/- and fVIII+/+ (WT) mice with same genetic background (C57BL/6) prior to and after reconstitution with recombinant FVIII-SQ and variants via a hydrodynamic approach. Plasma VWF antigen was determined by a sandwich ELISA assay and plasma VWF multimers were determined by 1% agarose gel electrophoresis and Western blotting. We showed that plasma VWF antigen levels in the fVIII-/- mice (n=18) were increased by ∼2.0 fold as compared with those in the WT mice (n=14). No difference in the ratio of ultra large (UL)-VWF to dimer was observed between the fVIII-/- mice and the WT mice (p>0.05). These data suggest that lack of FVIII may impair plasma VWF homeostasis. To assess whether plasma FVIII affects VWF proteolysis in vivo, plasma VWF multimer distribution was determined by agarose (1%) gel electrophoresis and Western blotting in the fVIII-/- mice 48 hours after injection of a series of endotoxin-free expression plasmids encoding various FVIII variants/fragments (i.e. plasmids diluted in 2 ml normal saline and injected into tail vein within 5 seconds). We showed that the ratio of the UL-VWF multimers to the dimer in plasma of fVIII-/- mice receiving normal saline alone was 1.70 ± 0.59 (means ± SD) (n=10). However, the ratios in plasma of fVIII-/- mice receiving plasmids encoding canine FVIII-SQ, human FVIII-SQ, human FVIII-HC+LC, and FVIII-LC were 0.44 ± 0.37 (n=20), 0.88 ± 0.18 (n=9), 0.40 ± 0.20 (n=5), and 0.97 ± 0.29 (n=9), respectively. These ratios were dramatically reduced compared with that in fVIII-/- mice receiving normal saline alone (p values<0.05∼0.001). Our hydrodynamic injection approach resulted in plasma levels of FVIII-SQ, FVIII-LC+HC and FVIII-LC between 150% and 200% of the WT. In contrast, a hydrodynamic injection of plasmid encoding human FVIII-HC or FVIII-Δa3LC did not prevent the accumulation of plasma UL-VWF multimers in fVIII-/- mice. We therefore conclude that FVIII, through the high affinity binding interaction between its light chain and D′D3 domain of VWF, may play a critical role in maintaining VWF homeostasis under (patho) physiological conditions. Disclosures: No relevant conflicts of interest to declare.
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Rosenthal, Allison C., Amylou Constance Dueck, Katherine Gano, et al. "A Phase II Clinical Trial of Rituximab, Cyclophosphamide, Bortezomib, and Dexamethasone (R-CyBor-D) in Relapsed Low Grade and Mantle Cell Lymphoma." Blood 124, no. 21 (2014): 4410. http://dx.doi.org/10.1182/blood.v124.21.4410.4410.
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Abstract Introduction Non-Hodgkin lymphoma responds to single agents such as cyclophosphamide, combination therapy such as CVP and immunotherapy with monoclonal antibodies such as rituximab. There is no consensus on the optimal treatment for relapsed low grade or mantle cell lymphoma. Based on the success and tolerability of combining alkylating agents with proteasome inhibitors in multiple myeloma, a phase II clinical trial of rituximab, cyclophosphamide, bortezomib, and dexamethasone (R-CyBor-D) was designed to explore the efficacy and safety of this combination in relapsed low grade and mantle cell lymphoma (MCL). Methods This trial enrolled relapsed patients at Mayo Clinic from October 2008 to March 2014. Eligibility required age≥18; biopsy proven follicular grades 1 or 2 lymphoma (FL), MCL, small lymphocytic lymphoma/chronic lymphocytic leukemia, marginal zone B-cell lymphoma, or Waldenström’s macroglobulinemia (WM); life expectancy >3 months; ECOG PS 0, 1 or 2; measurable disease; Hb ≥8g/dl, ANC ≥1200/uL, platelet ≥75,000/uL, creatinine ≤1.5xULN, total bilirubin ≤1.5xULN, alkaline phosphatase ≤3xULN, AST ≤3xULN; and willingness to sign informed consent. Women of child bearing potential had pregnancy testing and all patients followed recommendations for contraception. Treatment included rituximab 375 mg/m2 IV on day 1 and oral cyclophosphamide 300 mg/m2, IV bortezomib 1.3 mg/m2, and oral dexamethasone 40 mg on days 1, 8, 15, and 22 in a 28-day cycle. Treatment was continued two cycles beyond best response or a maximum of 12 cycles. Allopurinol 300 mg on days 0-14 for the first cycle was strongly recommended. Results 21 patients were enrolled prior to study closure due to slow accrual. Bortezomib was initially given on days 1, 4, 8, and 11 in the first 16 patients, but was subsequently modified to days 1, 8, 15, and 22 due to significant peripheral neuropathy (PN). Median age was 69 years (range 51-80) and 13 (62%) were male. 62% had stage IV disease and 17 (81%) had 2 or more prior treatments with 3 (14%) having prior autologous stem cell transplantation. Histologies included FL-I (n=6), FL-II (n=2), MCL (n=8), and WM (n=5). Patients completed a median of 4 cycles of treatment (range 1-12), discontinuing due to 9 (43%) completion per protocol, 4 (19%) progression, 5 (24%) adverse events, 1 (5%) patient refusal, and 2 (10%) other reasons. Median follow-up is 32.8 months (0.9-54.8). CR or PR as best response was observed in 13 (62%, 95% CI 38-82%; 4 CR [19%], 9 PR [43%]) patients. By histology, CR or PR was observed in 7 (88%) FL patients (4 CR, 3 PR); 2 (25%) MCL patients (both PR), and 4 (80%) WM patients (all PR). CR or PR was observed in 10/16 (62%; 4 CR, 6 PR) before and 3/5 (60%; all PR) after the change in bortezomib schedule. Among 13 patients with CR or PR, median duration of response was 25.9 months (95% CI 8.0-not reached). Median PFS and OS were 11.6 months (95% CI 3.8-not reached) and 54.8 months (95% CI 24.6-54.8), respectively. At least one Gr≥3 adverse event at least possible related was observed in 14 (67%) patients, the most common being leucopenia (7, 33%), neutropenia (7, 33%), thrombocytopenia (6, 29%), anemia (5, 24%), PN (5, 24%), and fatigue (3, 14%). Peripheral sensory neuropathy at least possibly related was Gr1, Gr2, and Gr3 in 5 (24%) patients each, with a lower rate observed for patients after the change in bortezomib schedule (before 13/16 [81%] Gr≥1, after 2/5 [40%] Gr≥1). Among 14 patients who completed a baseline and at least one post-baseline FACT/GOG-NTX additional concerns questionnaire, 10 (71%) reported clinically meaningful (≥3-point) worsening in patient-reported neurotoxicity (8/11 [73%] before and 2/3 [67%] after the change in bortezomib schedule). Conclusions Our results suggest R-CyBor-D is a safe and effective combination in patients with relapsed low grade and mantle cell lymphomas. High response rates were seen in FL and WM. The majority of significant AE’s were hematologic. However, sensory neuropathy was common with twice weekly dosing of bortezomib and lessened with weekly dosing. Determination of optimal treatment regimens in this population remains an unmet need. Additional clinical trials including larger patient numbers are necessary to confirm these observations. This trial was sponsored by Millennium Disclosures Off Label Use: bortezomib was used in combination therapy to treat relapsed low grade lymphomas and Waldenstrom's macroglobulinemia. Bergsagel:Novartis: Research Funding; Constellation Pharmaceutical: Research Funding; OncoEthix: Research Funding; MundiPharma: Research Funding. Tiedemann:Janssen: Honoraria. Reeder:Millennium, Celgene, Novartis: Research Funding.
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Shah, Harsh, Seongho Kim, Paramveer Singh, et al. "Post-ASCT Outcomes in Multiple Myeloma Patients Who Underwent ASCT with G-CSF+Plerixafor Versus G-CSF Mobilized Graft." Blood 132, Supplement 1 (2018): 3350. http://dx.doi.org/10.1182/blood-2018-99-113713.
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Abstract BACKGROUND: Impact of Plerixafor (P) mobilized stem cells on immune reconstitution of autologous stem cell transplant (ASCT) patients has not been established. Early lymphocyte recovery (Absolute lymphocyte count of > 1 K/uL at day 30 after transplant) has been established to predict outcomes in multiple myeloma (MM) patients. The purpose of this study was to evaluate lymphocyte recovery in MM patients who underwent ASCT with stem cells mobilized with G-CSF vs G-CSF+P. Secondary objective was to evaluate the survival outcomes. METHODS: This is a retrospective analysis of MM patients who underwent first ASCT between 2008 and 2016 with either G-CSF or G-CSF+P mobilization at Karmanos Cancer Institute in Detroit, Michigan. Plerixafor was used per institutional guidelines when the peripheral CD-34+ve cell-count was < 20/ uL on day 5 of G-CSF mobilization. 610 total patients were identified. Mobilization agents used were G-CSF alone (n= 469) or G-CSF+P (n= 141). All patients underwent transplant after Melphalan (M) conditioning and dose of M was at treating physician's discretion (140 vs 200 mg/m2). The primary endpoint was the Absolute Lymphocyte Count at day 30 (ALC30). Secondary endpoints were PFS and OS Univariable and multivariable Cox proportional hazards regression models were fit to assess associations between ten pre chosen predictors( age, race, stage at diagnosis, doublet vs. triplet therapy, lines of treatment, disease status, mobilization agents, melphalan dose, ALC at day 30, post- transplant maintenance) and survival benefit (PFS and OS). RESULTS: Median age of patients was older in G-CSF+P group (62 vs 60 years, p=. 006) and they were more likely to receive triplet therapy (82 vs 72%, p=. 015) for induction compared to G-CSF group (Table 1). Patients in G-CSF group were more likely to receive greater than one line of treatment before transplant (p=. 006). Disease status at transplant was similar between the two groups. G-CSF patients received higher dose of M (at 200mg/ m2) more frequently (69 vs. 58%, p = 0.010) and median cell dose infused was higher in G-CSF group (3.19 vs 2.88 x106 CD 34+ve-cells/Kg, p= 0.001). Primary endpoint, ALC30, was 1.3 K/uL(.1-4.5) and 1.2 K/uL(.1-5.1) for G-CSF and G-CSF+P, respectively (p=. 608). Median day to neutrophil recovery were similar in both groups (ANC of 500 at Day 12). Post-transplant maintenance use was similar between the two groups. The median PFS was 2.46 years (95% CI, 2.14 to 3.15) and 2.77 years (95% CI, 1.99 to 3.27) for G-CSF and G-CSF+P, respectively (HR: 1.128; 95% CI, (.843-1.509); p=. 417) (Figure 1). The median OS was 6.09 years (95% CI, 4.55 to NR) and 3.73 years (95% CI, 3.20 to NR) for G-CSF and G-CSF+P, respectively (HR: 1.638; 95% CI, (1.118-2.399); p=. 011) (Figure 2) .In MVA, higher stage at diagnosis, less than PR before ASCT, and no post-transplant maintenance therapy were associated with worse PFS and OS. More lines of treatment adversely impacted PFS. Use of G-CSF+P for mobilization and Melphalan dose ≤ 200-mg/ m2 adversely impacted OS. ALC30 did not impact PFS or OS in MVA. There were no significant differences in causes of death among the 2 groups. CONCLUSIONS: In this large, retrospective analysis of MM patients mobilized with G-CSF vs G-CSF + P, there was no significant difference in lymphocyte recovery. Higher Melphalan dose resulted in improved OS in the MVA. There was an overall survival difference favoring the G-CSF group, however, differences in baseline characteristics not accounted for in the MVA may be responsible for this observation. A Prospective study comparing these mobilization regimens including patients with similar baseline characteristics is necessary to confirm this finding. Disclosures Deol: Kite Pharmaceuticals: Consultancy; Novartis: Consultancy.
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Chu, Yaya, Julie-An Talano, Lee Ann Baxter-Lowe, et al. "Sustained Donor Chimerism and Rapid Immune Cell Reconstitution Following Familial Haploidentical (FHI) CD34 Enriched Stem Cell Transplantation with Pbmnc Addback in Patients with High Risk Sickle Cell Disease (SCD) (IND 14359)." Blood 134, Supplement_1 (2019): 1990. http://dx.doi.org/10.1182/blood-2019-126757.
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Background: Allogeneic stem cell transplantation (AlloSCT) from an HLA-matched sibling donor is the only known curative therapy in patients with high-risk SCD (Talano/Cairo, EJH, 2015). Unfortunately only about 15% of high risk patients with SCD have an HLA-matched unaffected sibling donor. T cell depletion has been employed to reduce AGVHD e.g., CD3/CD19 cell depletion (Barfiled RC, et al, Cytotherapy, 2004), αβ T-cell/CD19 cell depletion (Locatelli F, et al, Blood, 2017), CD34+ positive selection (Aversa F, et al, NEJM, 1998). MUD transplantation in high-risk SCD recipients has shown unexpectedly high rates of CGVHD (Shenoy et al, Blood, 2016). We reported a very low incidence of acute and chronic GVHD in pediatric recipients receiving CD34 enriched HPC products with PB MNC addback with 2 x 105 CD3/kg from MUD donors (Geyer/Cairo et al, BJH, 2012). Furthermore, rapid NK cell reconstitution after AlloSCT is associated with a significant improvement in 1yr OS (Pical-Izard, BBMT, 2015; Dunbar et al, Hematologica, 2008). Recently, we reported promising results for high-risk SCD patients at 1 year follow-up after FHI CD34 enriched/PBMNC with addback AlloSCT with the probability of 1-year overall survival (OS) n=17; 88.2% (CI95: 60.6-96.9) (Talano/Cairo, ASH, 2017), expanding the donor pool and hopefully improving outcomes for high-risk patients with SCD. Objective: To investigate donor chimerism, immune cell reconstitution and NK cell function in high-risk patients with SCD following AlloSCT using FHI CD34 enrichment/PBMNC (2 x 105 CD3/kg) addback. Methods: Twenty-one eligible SCD patients (2-<21 yrs) were enrolled. Nineteen patients received hydroxyurea, azathioprine, fludarabine, busulfan, thiotepa, cyclophosphamide, R-ATG, and TLI followed by FHI AlloSCT to date (Talano/Cairo, ASH, 2017). CD34 cells were enriched using the CliniMACS® system, kindly provided by Miltenyi Biotec, with a target dose of 10 x 106 CD34+ cells/kg with a PBMNC addback dose of 2x10*5 CD3/kg in the final product. Whole blood and RBC chimerism (estimated using CD71 to isolate an eythroid lineage-enriched fraction) were determined by STR. Immune cell and subset reconstitution was assessed by flow cytometry as previously described (Geyer/Cairo et al. BJH, 2012). NK function was determined by cytotoxic activity against K562 tumor targets at 10:1 E:T ratio by europium release assay and intracellular LAMP-1 (CD107a) and granzyme B expression by flow cytometry as previously described (Chu/Cairo et al, Can Imm Res, 2015). Results: There was 100% engraftment of neutrophils and platelets. The median day post-HISCT to neutrophil and platelet engraftment was +9 and +19, respectively. Whole blood donor chimerism (mean±SEM) at 1-year, 2-year, and 3-year post-HISCT was 97±1%, 97±1%, 97±1%, respectively (Fig.1). Donor chimerism for CD71+ RBCs (mean±SEM) at 1-year, 2-year, 3-year post-HISCT was 97±2%, 98±1%, 98±1%, respectively (Fig.1). Immune reconstitution of CD3, CD4, CD8, and CD19 was evaluated. The time to recovery of minimally normal levels post-HISCT of CD3 (800 cells/ul), CD4 (400 cells/ul), CD8 (200 cells/ul), and CD19 (200 cells/ul), was approximately 365, 365, 270, and 60 days post-HISCT (Fig.2), respectively. Probability of Grade II-IV AGVHD, CGVHD and 1 year EFS/OS was 6.2%, 6.7% and 90%, respectively. NK reconstitution was rapid and peaked at d+30 (36±9%, 2710cells/ml). NK cytotoxicity against K562 at a E:T=10:1 peaked at d+30 (26±3%) and d+180 (28±3%) vs at pre-t (16±2%) (p<0.01) (Fig. 3A). Consistent with increased NK cytotoxicity, CD56dimCD3- subset was increased at d+30 vs pre- HISCT (p<0.05). The NK activation marker, CD107a peaked at d+30 (38±9%) and d+180 (41±6%) (Fig.3B). More over, reconstituted NK cells expressed higher level of activating receptors NKp46 (24±9%), NKG2D (32±9%) and KIR2DS (8±3%) and inhibitory receptors NKG2A (33±9%), CD94 (28±9%) and KIR2DL2/3 (11±2%) at d+30 compared to other time points. Conclusion: Despite a 5 log depletion of T cells, the PBMNC addback (fixed at 2 x 105 CD3/kg) facilitated rapid donor chimerism and immune reconstitution with a low probability of Grade II-IV AGVHD. The rapid NK reconstitution may have in part contributed to the excellent 1yr OS in the FHI study. (Supported by FDA R01FD004090 (MSC)). Disclosures Cairo: Jazz Pharmaceuticals: Other: Advisory Board, Research Funding, Speakers Bureau; Osuka: Research Funding; Miltenyi: Other: MTA.
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Natale, Annalisa, Stefano Pulini, Antonio Spadano, Anna Morelli, and Giuseppe Fioritoni. "Leuco-Thrombocytopenia Due to Splenomegaly in a Patient Affected by Retroperitoneal Fibrosis." Blood 112, no. 11 (2008): 4569. http://dx.doi.org/10.1182/blood.v112.11.4569.4569.
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Abstract Idiopathic retroperitoneal fibrosis (RPF) is a rare clinical entity characterized by the progressive proliferation of connective tissue in the retroperitoneum. The chronic inflammatory process can entrap the retroperitoneal structures, mainly the ureters and the great vessels. Although the causes are unknown, immunogenetic factors and immunopathologic/autoimmune mechanisms are probably involved. The pathogenesis appears to be related to IgG4 autoimmune mechanisms (“hyper-IgG4 disease”). Surgical treatments are frequently performed such as ureterolysis and aneurysm repair; steroids and immunosuppressive agents are also used. In January 2008 a 62-year-old Caucasian man was referred to our institution for mild leucopenia and progressive thrombocytopenia. In 1999 he had a diagnosis of RPF treated surigically and complicated by chronic renal failure. He did not undergo regular follow-ups during the following years. When he came to our attention his peripheral blood count showed: Hb 14.5 g/dl, WBC 3.800/uL (N 60%, L 28%, M 8%), Plt 79.000/uL, confirmed by numerous measurements. He did not present signs or symptoms of cutaneous or mucosal bleeding and he did not report any recurrence of infectious episodes. At physical examination the spleen was palpable at 5 cm from the ribs, neither liver enlargement nor superficial lymphoadenopathies were noted. A peripheral blood (PB) smear showed only anisocytosis of red blood cells. To exclude an underlying hematologic disorder a bone marrow (BM) aspiration and a BM trephine biopsy were performed, both demonstrating a regular representation of the three hematopoietic series without any pathologic patterns. Cytogenetic examination revealed normal karyotype and molecular biology analyses resulted negative for Bcr/Abl rearrangement and for mutation V617F of JAK2 gene. Routine laboratory tests including liver function, LDH, Beta2 microglobulin serum levels, autoimmune tests, PB mononuclear cell immunophenotyping, viral sierology resulted within normal range. Abdominal ultrasound showed about 95 cm2 homogeneous splenomegaly and revealed an hyperechogenic rounded mass measuring 5–6 cm that completely embraced the splenic hilum. Splenic vein at the source was not visible and splenic flow was not measurable because of the hilum compression. Splenic vein in the retropancreatic site was measurable only partially: it presented thin caliber with normal directed blood flow inside. The abdominal CT exam confirmed the presence of a 5.6×7 cm solid tissue mass embracing the pancreatic tail and the splenic vessels and it extended across the spleno-pancreatic ligament. Moreover, the mass also involved the upper part of the left adrenal gland expanding until peri-renal space. Radiologically the mass was considered as RPF. In this case the retroperitoneal fibrotic tissue compresses the splenic hilum reducing the blood flow through the spleen thus causing congestive splenomegaly. The increase size of the spleen is responsible for thrombocytopenia as well as for leucopenia. The mechanism underlying splenomegaly-related thrombocytopenia is an induction of a reversible pooling of up to 90 percent of total body platelets. Both platelet production and the survival of platelets within the spleen are normal. Pooling is the major factor responsible for thrombocytopenia in uncomplicated splenomegaly. In this patient no hematologic specific treatment is indicated since neither thrombocytopenia nor leucopenia have clinical relevance. The aim of the therapy should be to reduce the progression of the fibrotic tissue to prevent further organ-related damages.
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Araujo, Marina Campos, Ilana Nogueira Bezerra, Flávia dos Santos Barbosa, et al. "Consumo de macronutrientes e ingestão inadequada de micronutrientes em adultos." Revista de Saúde Pública 47, suppl 1 (2013): 177s—189s. http://dx.doi.org/10.1590/s0034-89102013000700004.
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OBJETIVO: Estimar o consumo de energia e nutrientes e a prevalência de ingestão inadequada de micronutrientes entre adultos brasileiros. MÉTODOS: Foram analisados dados do Inquérito Nacional de Alimentação da Pesquisa de Orçamento Familiar 2008-2009. O consumo alimentar foi avaliado por dois dias de registro alimentar não consecutivos. Um total de 21.003 indivíduos (52,5% mulheres) entre 20 e 59 anos de idade participou do estudo. A ingestão usual de nutrientes foi estimada pelo método proposto pelo National Cancer Institute. As prevalências de ingestão inadequada de micronutrientes foram obtidas pelo método da necessidade média estimada (EAR) como ponto de corte. Para manganês e potássio, a Ingestão Adequada (AI) foi usada como ponto de corte. A ingestão de sódio foi comparada com o nível de ingestão máximo tolerável (UL). A prevalência de inadequação da ingestão de ferro foi determinada por abordagem probabilística. Os dados foram analisados de acordo com a localização do domicílio (área urbana ou rural) e as macrorregiões do país. RESULTADOS: A média do consumo energético foi de 2.083 kcal entre os homens e 1.698 kcal entre as mulheres. Prevalências de inadequação maiores ou iguais a 70% foram observadas para cálcio entre os homens e magnésio, vitamina A, sódio em ambos os sexos. Prevalências maiores ou iguais a 90% foram encontradas para cálcio entre as mulheres e vitaminas D e E em ambos os sexos. Prevalências menores que 5% foram encontradas para ferro entre os homens e niacina para homens e mulheres. No geral, a prevalência de ingestão inadequada foi mais acentuada na área rural e na região Nordeste. CONCLUSÕES: O consumo de energia é maior entre indivíduos residentes em áreas urbanas e da região Norte. Os grupos com maior risco de ingestão inadequada de micronutrientes são as mulheres e os que residem na área rural e na região Nordeste.
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Strouse, John J., Joshua Field, Regina D. Crawford, and Sophie Lanzkron. "Antecedent Transfusion and Primary Hemorrhagic Stroke in Adults with Sickle Cell Disease." Blood 112, no. 11 (2008): 1437. http://dx.doi.org/10.1182/blood.v112.11.1437.1437.
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Abstract Primary hemorrhagic stroke is an uncommon but serious complication of sickle cell disease (SCD) with mortality from 20 to 65%. Proposed risk factors include previous ischemic stroke, aneurysms, low steady-state hemoglobin, high steady-state leukocyte count, acute chest syndrome, and transfusion. We performed a retrospective case-control study to evaluate risk factors for primary hemorrhagic stroke in adults (age &gt;18 years) with SCD from Johns Hopkins and Barnes- Jewish Hospitals and Duke University Medical Center from January 1989 to April 2008. Cases had SCD and intraparenchymal (IPH), subarachnoid (SAH), or intraventricular (IVH) hemorrhage confirmed by neuroimaging or analysis of cerebrospinal fluid; traumatic hemorrhages and hemorrhagic conversion of ischemic strokes were excluded. Controls had SCD and ischemic stroke (focal neurological deficits with corresponding cerebral infarcts by neuroimaging). Both were identified by searching the hospital discharge database using ICD-9 codes for acute stroke and SCD and reviewing divisional records. We compared continuous variables by Student’s t-test and calculated odds ratios with exact methods. We identified 19 cases (mean age 29 years, range 18 – 66, 42% male) and 18 controls (mean age 34 years, range 19 – 61, 39% male). Most cases (14/18) had sickle cell anemia (HbSS) and 22% had a prior overt stroke; controls had HbSS (9/17), HbSB0thalassemia (1), or HbSC (7) and 41% had a history of overt stroke. Cases presented with headache (89%) and seizure (37%) and less frequently hemiparesis (27%). Controls presented with hemiparesis (78%), headache (57%), and rarely seizure (11%). Twelve cases had IPH including those with extension to the ventricles (1), subarachnoid (2) or both (2); six had SAH including ventricular extension (1). Potential causes of hemorrhagic stroke included moyamoya (4), aneurysms (3), anticoagulation (1) and ateriovenous malformation (1). Four cases (21%) and no controls died during the initial hospitalization. More cases (82%) than controls (44%, P&lt;0.05) had elevated systolic blood pressure at the time of stroke. At steady-state, cases had lower hemoglobin (mean ± SEM 8.5 ± 0.6 g/dl vs. 9.7 ± 0.6 g/dl), lower blood pressures (systolic 121 ± 4 vs. 127 ± 6 mm Hg, diastolic 71 ± 4 vs. 72 ± 9 mm Hg) and higher platelet counts (399,231 ± 74,024/ul vs. 362,200/ul ± 39,927/ul) than controls, but these differences were not statistically significant. Mean hemoglobin concentration at the time of stroke increased 1.3 g/dl (19%) from steady-state in cases and 0.01 g/dl (2%) in controls (p&lt;0.05). Seven cases had simple transfusions (between 1 and 11 days before their primary hemorrhagic stroke) in preparation for surgery (3), and for aplastic crisis (1), bacteremia (1), acute renal failure (1), or suspected acute chest syndrome (1). Only 1 control was transfused; and 1 with HbSS had a hemoglobin of 14.5 g/dl at the time of stroke (from excessive erythropoietin administration). In this group of adults with SCD, primary hemorrhagic stroke was associated with antecedent transfusion. Identifiable causes include moyamoya from obstructive cerebral vasculopathy, aneurysms and other vascular malformations, and rarely coagulopathy. Mortality was similar to that previously described. The association of recent transfusion and cerebral vasculopathy with hemorrhagic stroke suggests caution in the use of simple transfusion in adults with SCD and moyamoya or cerebral aneurysms. Table 1: Associations with Primary Hemorrhagic Stroke Variable Odds Ratio (95% CI) P-value Genotype (HbSS vs. other) 3 (0.6 – 17) NS Moyamoya 5 (0.4 – 260) NS Transfusion in the last 14 days 13 (1.3 – 630) &lt;0.02 NSAID in the last 14 days 2.9 (0.3 – 36) NS
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Cesaro, Simone, Gloria Tridello, Andrea Giulio Zanazzo, Stefano Frenos, Chiara Messina, and Sandro Dallorso. "PEG-Filgrastim for Autologous Peripheral CD34+ STEM CELL Collection in Pediatric Oncological PATIENTS: A PHASE II STUDY." Blood 112, no. 11 (2008): 2312. http://dx.doi.org/10.1182/blood.v112.11.2312.2312.
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Abstract Pegfilgrastim (Peg-f) is the pegylated long-acting formulation of filgrastim that allows recovery from chemotherapy-induced neutropenia by single-shot administration. Data on adults show that Peg-f is safe and efficacy also in CD34+ peripheral blood stem cell collection. From May 2007 to July 2008, Peg-f was administered to 34 consecutive patients from 4 Italian pediatric centres at a dosage of 100 ug/kg (max 6 mg) for PBSC purposes. They were 21 male and 13 female, median age at diagnosis of 10 years (range 3–18), affected by solid tumour, 30 (Ewing, 9; Medulloblastoma, 5; Neuroblastoma, 5; brain tumours, 4; other, 7), acute lymphoblastic leukaemia or non-Hodgkin lymphoma, 4. The remission status at PBSC was: CR 8 (24%), VGPR 5 (15%), PR 19 (56%), SD or not known 2 (6%). The median weight was 35.5 kg (range 13.5–86) and the median number of planned infusion was 1, range 1–3. Different regimens of mobilizing chemotherapy were used, etoposide, cyclophosphamide and ifosphamide being the most frequent drugs administered. The median time to first PBSC was 10 days, range 6–15. The least threshold for CD34+ collection (20 cell/ul) was obtained in 28 of 34 patients (82%), the median value of CD34+ peak being 140 (range 20–1988). Successful PBSC was obtained in 27 patients (79%) because one very low weight child failed it for suboptimal vascular access. Sixteen of 27 patients (59%) achieved the target PBSC collection with 1 leukapheresis whilst 10 patients required a second leukapheresis. The median collection yield was 8 (range 1.9–116) and 2.45 (range 1–6) CD34+ x 106/kg) for the first and second leukapheresis, respectively. No Peg-f related adverse effects were reported. So far, 15 of 27 patients (56%) underwent a first autologous transplant whilst 4 and 1 underwent a second and third transplant, respectively. The median time from PBSC to first transplant was 64 days (range 10–154) and the median value of CD34+ x 106/kg infused was 7 (range 3–299). Different conditioning regimen were used, myeloablative doses of busulfan, thiothepa, melphalan, and etoposide being the drugs most frequently used. After a median f-up of 29 days from first transplant (range 16–176), all patients achieved a PMN count &gt; 0.5 x 109/l in a median time of 13 days (range 5–23) whilst 14 and 12 achieved a transfusion-unsupported PLT count &gt; 20 and &gt; 50 x 109/l in a median time of 13 (range 5–23) and 15 days (range 12–36), respectively. Prophylactic post-transplant G-CSF was used in 7 of 15 patients (47%) for a median time of 7 days (range 1–11). All 5 patients who performed a second or third transplant successfully engrafted for PMN and PLT. All 15 transplanted patients were alive at latest f-up. We conclude that Peg-f single-shot CD34+ mobilisation is safe and efficacy also in pediatric patients. Further prospective studies are needed to investigate the non-inferiority or superiority of Peg-f vs. filgrastim in PBSC.
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Horstman, Larry Lawrence, Yeon-Soong Ahn, Jacob Esquenazi, Wenche Jy, Carlos J. Bidot, and Camile Ortega. "Elevated Cholinesterase Activity in Patients with TIA and Other Thrombotic Disorders." Blood 114, no. 22 (2009): 2991. http://dx.doi.org/10.1182/blood.v114.22.2991.2991.
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Abstract Abstract 2991 Poster Board II-967 Background. The natural function of ACTH in blood is not well defined. However elevated plasma level was reported in patients with chronic inflammation, suggesting as one of inflammatory markers. Erythrocytes possess membrane-bound acetylcholinesterase (AChE) while plasma contains a less specific cholinesterase (ChE). We reported at a previous meeting [Blood 2008, 112(11) Abst #3849] that AChE activity of RBC-derived microparticles (RMP) is 6 times higher than those in PMP. In this study we measured plasma ACTH levels in several groups and encountered unexpectedly high plasma ChE activities in patients with TIA and other thrombosis. Methods. (i) Patient population. A series of n=108 consenting patients were recruited sequentially having various disorders For purpose of analysis, they were divided in 2 main groups: n=53 with thrombosis (TBS), F/M 27/26; and n=55 non-TBS, F/M 24/31. Thrombosis group consists of venous and arterial thrombosis including those with TIA. Non TBS group consists of anemias, thrombocytopenias including ITP, MDS. (ii) Assay was essentially by Ellman's method. In our system, milli-absorbance units/min (mA/min) x 0.065 = umols substrate cleaved/min. Values reported here are in unitsof mA/min per mL plasma. Normal controls (NC, n=14) had a cutoff of 3000 mA/min per mL plasma, = mean +2SD. (iii) Sample handling. Platelet-poor plasma (PPP) was prepared by centrifuging 10 min at 1800 xg, then frozen in aliquots. For assay, it was diluted 1:20 with saline, then 5 uL and 10 uL were used in 96-well microtiter plate. Results: (i) Significantly higher ChE activity was observed in thrombosis (TBS) patients compared to non-TBS. Mean value ±SD in TBS was 2928 ±773, and in Non-TBS was 1897 ±713 (units as above). This difference was significant, p<0.001. (ii) When analyzed elevated levels of ACTH above 2SD of normal controls (n=26) between 2 groups, the TBS group had elevated ChE (>3000) in 30% of patients, while the Non-TBS had elevated ChE in 7.8%. (iii) Further analysis among thrombosis group revealed that the subgroup with neurological TBS (TIA, minor strokes) had the most consistent elevations of ACTH; 10 of15 with TIA group (66%) had ChE activities >3000. Summary/ Discussion. Although ChE and AChE in blood has long been studied, to our knowledge, this is the first report to show a relation between plasma ChE and thrombosis. Its elevation is very pronounce in thrombosis of the CNS, manifesting as TIA. Further study is warranted to elucidate how ChE is related to AChE of the CNS and on red cells. Disclosures: No relevant conflicts of interest to declare.
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Amaru, Ricardo, Ariel Amaru, Hortensia Miguez, et al. "Successful Treatment of HU-Refractory Polycythemia Vera with Atorvastatin and Low Dose Hydroxyurea. Results from a Pilot Study in Bolivia." Blood 126, no. 23 (2015): 5621. http://dx.doi.org/10.1182/blood.v126.23.5621.5621.
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Abstract Background Polycythemia Vera (PV) is a clonal myeloproliferative neoplasm, characterized by the JAK2V617F mutation. The main goal of current therapies for PV is to prevent thrombotic events and delay transformation to Myelofibrosis (MF) or Acute Myeloid Leukemia (AML).Treatment for PV to keep an hematocrit (Hct) level <45 %, has been associated with a reduction in cardiovascular deaths and thrombotic events (Marchioli, R et al. NEJM 2013). Currently, low-risk PV patients (<60 years and no previous thrombotic events) are treated with aspirin and phlebotomy while high-risk patients require additional cytoreductive therapy, usually with Hydroxyurea (HU). Resistance to HU is associated with an increased risk of transformation and reduced survival. This is why for HU-refractory patients, second line treatments with interferon alpha, anagrelide or even ruxolitinib are recommended. In Latin America, because of high cost and drugs availability, this last group reflects difficulties to be treated. Because statins have been reported to modulate the erythroid clonogenic activity of normal BM erythroid colonies we performed a pilot study to investigate in vitro and in vivo the biologic and clinical activity of atorvastatin in PV patients Patients and Methods Ten high risk PV patients with a median age of 64.3 years (range 58-73) entered into this study. The diagnosis of PV was done according to the 2008 World Health Organization diagnostic criteria and patients were stratified according to an algorithm proposal provided by Griesshammer et al. (Ann Hematol, 2015). The definition of HU resistance (Barosi, G et al.: BJH 2009) was applicable to five patients (median age 63.9 years) failing to achieve a satisfactory hematologic response upon treatment with more than 2 g of HU, 100 mg of Aspirin and phlebotomies. The assessment of the JAK2V617F mutation was performed as previously described (Guerini et al.: Leukemia 2009). Colony assay, proliferation and apoptosis tests were performed with or without Simvastatin (3.5 uM), as previously described (Amaru, A, Experimental Hematology 2012), on cell lines (UKE1 and K562) and bone marrow mononuclear cells obtained from PV patients and healthy donors. Patients with HU refractory PV (n=5) and high risk PV with hypercholesterolemia (n=5) were eligible to receive Atorvastatin (20 mg/day) added on the top of the ongoing treatment with phlebotomies, Aspirin (100 mg/day) and cytoreductive HU therapy (500 mg/day). All treated patients were high altitude residents (> 3.600 m.a.s.l.) of La Paz (Bolivia) where the normal Hct level of healthy subjects is 48-57% for men and 44-54% for women. This pilot study was approved by the Review Board of the Hospital and the University of San Andres, La Paz. Results In a preliminary set of in vitro proliferation cell assays, simvastatin (3.5 uM), added for 5 days, induced a 33% inhibition of cell proliferation of UKE-1 (JAK2V617F mutated) as compared to 5 % of K562 (BCR/ABL positive). A comparable result was obtained in a 7-day clonogenic cell assay where the colony inhibition was 50 % for UKE-1 and 10 % for K562. On the basis of these results similar experiments were also performed using BM mononuclear cells derived from PV patients and healthy donors. In these experiments performed with the addition of simvastatin, it induced a 41% of inhibition in BFU-E colonies of PV patients and a 25% of inhibition in healthy donors. Furthermore, BFU-E colonies inhibited by simvastatin presented a decrease in hemoglobinization and the size of colonies. HU refractory PV patients and High-risk PV patients with hypercholesterolemia treated with the addition of Atorvastatin, Aspirin, cytoreductive HU and phlebotomies; after a follow-up of 2.6 years (1-7 years), induced a decrease of WBC from 16.500 to 9.270/ul, Hct 61.1 to 52.3% and PLT 457.900,000 to 324.7000/ul. The number of required phlebotomies is reduced in comparison to the required at starting treatment. None of the patients presented thrombotic or cardiopulmonary event. One patient died within two years of starting treatment, due to complications of diabetes mellitus. Conclusions In vitro and in vivo, statins showed some evidence of inhibitory activity of the hematopoiesis of PV patients. These preliminary results might indicate the opportunity to further investigate the potential clinical value of these molecules in the treatment of PV. Disclosures Off Label Use: Atorvastatin was used for its antiproliferative activity on myeloid progenitor cells shown by in vitro experiments.
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Devine, Steven M., Robert J. Soiffer, Marcelo C. Pasquini, et al. "HLA-Identical Sibling-Matched, CD34+ Selected, T Cell Depleted Peripheral Blood Stem Cells Following Myeloablative Conditioning for First or Second Remission Acute Myeloid Leukemia (AML): Results of Blood and Marrow Transplant Clinical Trials Network (BMT CTN) Protocol 0303." Blood 114, no. 22 (2009): 655. http://dx.doi.org/10.1182/blood.v114.22.655.655.
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Abstract Abstract 655 Allogeneic hematopoietic cell transplantation (HCT) is the most effective means to prevent relapse in patients (pts) with AML in complete remission (CR). However, quality of life and overall survival (OS) are often affected by both acute and chronic graft versus host disease (GVHD). GVHD is most effectively prevented by ex vivo T cell depletion (TCD) of the allograft, but has been limited in its use by logistical difficulties, lack of an FDA-approved method, and concerns regarding potential risk of graft rejection, post transplant infections, and leukemic relapse. Most reported TCD studies represent single centers, multiple disease types and processing methods with varying degrees of TCD, all of which affect outcome. Therefore we designed a trial using a single processing method providing extensive TCD that did not require post transplant GVHD prophylaxis involving adult pts with AML in first or second CR. We hypothesized that the undesired side effects of TCD HCT would be reduced if combined with a conditioning regimen that was highly immunosuppressive and anti-leukemic. The primary objective was to achieve a disease-free survival (DFS) rate at 6 months (mos) post transplant that exceeded 75%. Secondary objectives included assessments of engraftment, transplant related mortality (TRM), GVHD, relapse, and performance of a single TCD method (CD34+ cell selection using the Miltenyi CliniMACS device) at participating centers. From 10/2005 to 12/2008, 47 pts were enrolled and 44 transplanted at 8 different centers. Median age was 48.5 years (range 21-59) with 28 female and 16 male pts. Of 37 AML CR1 pts, 49% had an unfavorable cytogenetic or molecular risk profile. The conditioning regimen consisted of hyperfractionated total body irradiation (1375cGy in 11 fractions) with partial lung shielding, thiotepa (10mg/kg), cyclophosphamide (120mg/kg), and rabbit antithymocyte globulin (2.5mg/kg). The donors, all HLA-identical siblings, were given G-CSF for mobilization and scheduled to undergo at least 2 leukapheresis procedures to ensure a graft with a high CD34+ cell content. All allografts were CD34-enriched and were targeted to contain ≥ 5×10e6 CD34+ cells/kg and < 1.0×10e5 CD3+ cells/kg. The median CD34+ and CD3+ doses achieved were 8.1 × 10e6/kg (range 2.4-46.2) and 0.07 × 10e5/kg (range 0.01-0.85), respectively. The majority (81%) of pts received the targeted CD34+ cell dose and no pt received > 1.0×10e5 CD3+ cells/kg. No pharmacological GVHD prophylaxis was given post transplant. There were no significant toxicities related to infusion of the CD34 enriched allografts. The most common grade 3-5 regimen-related toxicities included grades 3 or 4 mucositis (39%) and grades 3-5 pulmonary abnormalities (11%). Only 1 pt experienced hepatic veno-occlusive disease. All pts engrafted rapidly with a median time to neutrophil recovery (ANC > 500/ul) of 11 days (range 9-19). There was 1 secondary graft failure. The assessed outcomes are shown below.Estimate (95% Confidence Interval)Outcome100 Days6 Months12 MonthsAcute GVHD II-IV20.5% (8.7 – 23.3%)Acute GVHD III-IV4.5% (0 – 10.6%)Chronic GVHD17.7% (5.8-29.6%)Extensive Chronic GVHD7.6% (0-15.7%)TRM17.8% (5.8-29.8%)Overall Relapse18.2% (5.9-30.5%)Relapse 1st CR9.6% (0- 19.8%%)Relapse 2nd CR64.3% (27.5-100%)DFS81.3% (66.1-90.2%)64.0% (46.5-77.1%)DFS 1st CR89.2% (73.7-95.8%)72.1% (53.0-84.6%)OS74.3% (57.3-85.4%) The absolute peripheral CD4+ cell count remained on average below 200/ul until day +365. Donor cell chimerism increased in the CD3+ cell compartment through day +365. There were 14 deaths. The most common causes of death were relapse (N=5) and pulmonary toxicity (N=4). The median follow-up of survivors is 489 days (range 96-776). There was no difference in OS or DFS for pts above or below the median age of 48.5 years. We conclude that TCD HCT following myeloablative chemoradiotherapy can be performed in a multi-center setting using a single TCD method without additional post transplant prophylaxis with excellent DFS and OS, consistent engraftment, low TRM, and low incidence of relapse even in pts with unfavorable risk AML in CR1. The low incidences of acute and chronic GVHD in the absence of post transplant prophylaxis were particularly encouraging. A follow-up study of TCD HCT in AML recipients of unrelated donor allografts is being planned by the BMT CTN Disclosures: No relevant conflicts of interest to declare.
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Barrantes C., Cecilio, Enrique Flores M., and José Ruiz C. "Caracterización de planteles de los sistemas de producción alpaquera de la sierra central del Perú." Revista de Investigaciones Veterinarias del Perú 29, no. 4 (2018): 1335. http://dx.doi.org/10.15381/rivep.v29i4.15182.
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El propósito del estudio fue caracterizar los planteles de tres sistemas de producción alpaquera de la sierra central: empresas y cooperativas comunales (ECC), granjas comunales (GC) y asociaciones de ganaderos (AG). Se realizó del 2006 al 2008, comprendiendo el diagnóstico estático de 28 hatos alpaqueros, evaluación de 30 planteles comunales y estimación de parámetros productivos del núcleo central de reproductores de alpacas (NCRA), procedentes de 22 unidades ganaderas. Los resultados fueron: a) Diagnóstico estático: las ECC exhibieron mejores indicadores que los otros sistemas de producción, en manejo y producción de fibra (ECC 5.2, GC 4.9, AG 5.0 lb/alpaca), extensión de tierras dedicadas a la crianza de alpacas (ECC 3225, GC 1024, AG 195 ha), acceso al mercado (ECC nacional, GC y AG local) y porcentaje de animales registrados (ECC 10.5, GC 0.9, AG 0%); b) Evaluación de planteles: las ECC mostraron mejores indicadores que los demás sistemas de producción, en proporción de madres clase Súper (ECC 23, GC 5, AG 0%) y padres Súper (ECC 86, GC 52, AG 0%), conformación del animal (ECC buena, GC y AG regular), finura de vellón (ECC fina, GC y AG media a gruesa), pasto cultivado (ECC 100, GC y AG 0%) y condición de pastizal (ECC y GC regular, AG pobre); y c) Parámetros productivos del NCRA: las alpacas provenientes de planteles de ECC respondieron mejor que los otros sistemas de producción en proporción de alpacas madres de clase Súper (ECC 13, GC 8, AG 2%), peso vivo a la esquila (ECC 59.3, GC 58.9, AG 53.1 kg), vellón sucio (ECC 2.4, GC 2.2, AG 2.4 kg) y longitud de mecha (ECC 8.9, GC 6.9, AG 7.0 cm). Los resultados muestran que las ECC muestran mejores parámetros que los otros sistemas de producción evaluados en el estudio.
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Borelli, Gabriel, Mercedes Zamora, Silvia Quiñones, et al. "Correlation Between Actual Stem Cells Collected By Apheresis and Predicted Stem Cells Based on Pre-Apheresis Peripheral Blood CD34+ Cell Counts." Blood 126, no. 23 (2015): 5440. http://dx.doi.org/10.1182/blood.v126.23.5440.5440.
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Abstract Introduction. Stem cell (SC) mobilization and collection from peripheral blood (PB) is a broadly used strategy in the setting of autologous stem cell transplantation (ASCT). An adequate correlation between CD34+ cell count in PB and CD34+ cell count in apheresis product is essential for the planning of the mobilization-apheresis process. Prediction of SC yield in the basis of peripheral blood stem cell (PBSC) number and blood volume processed (BVP) was proposed by Pierelli et al (Vox Sanguinis (2006)91:126-34). Objective. Evaluation of correlation between pre-apheresis PBSC count and CD34+ cell dose collected in the first apheresis procedure. Evaluation of correlation between predicted CD34+ yield by Pierelli's method and actual CD34+ yield collected in the first apheresis procedure. Patients and Methods. Eighty-four apheresis procedures performed to 79 patients in a single institution between 2008 and 2015 were retrospectively evaluated. Data analyzed included age, gender, body weight, diagnosis, date of first apheresis, pre-apheresis PB CD34+ counts, CD34+ cell dose collected in the first apheresis product and total BVP. Only patients in whom pre-apheresis PBSC count was available were included in this analysis. Median age was 52 years (16-66), 30 (38%) were females. Median body weight was 71 kg (47 - 120). Diagnosis was non-Hodgkin lymphoma (48%), multiple myeloma (24%), Hodgkin lymphoma (22%), acute myeloblastic leukemia (4%), amyloidosis (1%) and solid tumor (1%). Using the method described by Pierelli et al, predicted CD34+ yields were calculated (predicted CD34+ cells/kg= PB CD34+ cells/mL x 0.4 x BVP per kg (mL/kg). Correlation between variables was analyzed by Pearson's coefficient (r). An r value close to 1 indicates significant correlation between variables. An r value close to 0 indicates no statistical correlation. Predicted yields were classified in low (lower than 2 x 106 CD34+ cells / kg) (n=34), intermediate (2 to 5) (n=28) or high (higher than 5) (n=22), according with the conventional limits for SC dose in the setting of ASCT. Positive predictive value (PPV) of predicted yields was calculated as the proportion of actual yields falling into each category of predicted yields. Results. Median pre-apheresis PBSC count was 25 CD34+ cells / uL (5-310). Median BVP was 240 mL/kg (143-360). Median predicted CD34+ yield was 2.1x106 CD34+ cells/kg (0.5-29.41) and median actual CD34+ yield was 2.84 x106 CD34+ cells/kg (0.26-38.21). Pearson's correlation coefficient (r) between pre-apheresis PBSC and collected CD34+ cells was 0.842 (p=0.000). Pearson's correlation coefficient (r) between predicted and actual CD34+ was 0.836 (p=0.000). Median ratio actual CD34+ cells / predicted CD34+ cells was 1.10 (0.31-4.55). PPV of predicted yields higher than 5 x 106 CD34+ cells /kg was high (95%). Only 18% of cases with a predicted yield between 2 and 5 x 106 CD34+/kg had an actual CD34+ yield lower than 2 x 106 CD34+/kg. Conclusion. The results show a significant correlation between PBSC count and collected SC during the first apheresis procedure. A significant correlation between predicted and actual CD34+ yields reproduce what has been shown by others regarding the predictive power of this formula. The PPV of this method is higher for predicted CD34+ yields higher than 5 x 106 CD34+ cells/kg. Disclosures No relevant conflicts of interest to declare.
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Liu, Yang, Ali Tabarroki, Valeria Visconte, et al. "A Prognostic Scoring System for Unclassifiable MDS and MDS/MPN." Blood 120, no. 21 (2012): 1701. http://dx.doi.org/10.1182/blood.v120.21.1701.1701.
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Abstract Abstract 1701 Patients with features of MDS and MDS/MPN who do not fulfill diagnostic criteria for a specific subtype of MDS and MDS/MPN are categorized by the WHO 2008 diagnostic criteria as MDS-U and MDS/MPN-U. MDS includes RCUD, RCMD, RARS, RAEB-1, RAEB-2, MDS-U and 5q- syndrome while MDS/MPN includes CMML, JMML, atypical CML and MDS/MPN-U. The natural history of patients who belong to these disease subtypes are hetergeneous. Although included in currently accepted prognostic scoring schemes like the International Prognostic Scoring System (IPSS) in MDS, Revised IPSS, and MD Anderson prognostic scoring schemes, they represent a minority of patients in the cohort. Within MDS/MPN cases, the clinical heterogeneity of diseases that belong to this group has been recognized and has led to the development of the MD Anderson prognostic Scoring System for CMML. Similarly, a prognostic scoring system for JMML has also been devised to help in risk stratification and treatment decisions. However, there are no prognostic scoring systems for unclassified cases of MDS and MDS/MPN. Clinically, we observe stark differences in treatment responses and clinical outcomes between MDS/MPN-U and other MDS/MPN-subtypes, and MDS-U with other subtypes of MDS. In total, we studied 92 patients with unclassifiable cases seen at the Cleveland Clinic, including MDS/MPN-U (n=52 [57%]) and MDS-U (n=40 [43%]). Hematologic, bone marrow (BM), cytogenetic (metaphase cytogenetic [MC]/SNP-A) and survival data were collected. Survival comparisons were made by Kaplan-Meier analyses. Cox-proportional hazard ratio was used to determine factors predictive of outcomes. A p-value of ≤0.05 was considered statistically significant. In this cohort, median age at diagnosis was 69 years (20–88), 65% (60/92) were male, and 35% (32/92) were female. Median follow-up was 21 months. Median absolute neutrophil count (ANC) was 2.69k/uL (0–87), peripheral blood (PB) blasts 0% (0–70%), hemoglobin 9.6g/dL (5–15), and LDH 260 U/L (105–2113). SNP-A karyotyping was completed for 65 patients, and new cytogenetic mutations were detected in 72% (47/65): (gains [64%], losses [57%], UPDs [25%]). In 52% (49/92) of patients, we sequenced molecular mutations that typically confer poor prognosis in myeloid neoplasms, such as ASXL1, IDH1/2, EZH2, K/NRAS, CBL and TP53. This sequencing revealed a mutational frequency of 18% (9/49) in TET2, 14% (7/49) in ASXL1, 6% (3/49) in EZH2 exons 18–19, 2% (1/49) in CBL, 2% (1/49) in NRAS, and 4% (2/49) in TP53. No mutations were found in IDH1/2 and KRAS. In univariate analysis of clinciopathologic factors, the following factors were found to be associated with overall survival: ANC (≥8.5 vs <8.5k/uL) (p<.0001), presence of PB blasts (p<.0001), presence of immature myeloid cells (p<.0001), presence of BM blasts (>3% v. ≤3%) (p<.0001), age (≥65 vs <65) (p<.0003), LDH (≥550 vs <550U/L) (p<.0004), albumin (≤3.6 vs >3.6g/dL) (p<.0008), IPSS Risk Group (Int-2/high vs int-1 vs low) (p<.01), IPSS-R Risk Group (High/very high vs low vs very low) (p<.001), WBC (≥15 vs <15k/uL) (p<.001), Hgb (≤11.5 vs >11.5g/dL) (p<.003), % BM cellularity (>85 vs ≤85%) (p<.009), and number of cytopenias (3 vs 2 vs 1 vs 0) (p<.04). In multivariate analysis, age (HR=3.47 CI 1.85–6.51, p=.001), ANC (HR=2.27 CI 1.15–4.49, p=.02), Hgb (HR=2.11 CI 1.07–4.14, p.03), peripheral blasts (HR=2.27 CI 1.19–4.36,p=.01) and LDH (HR=2.40 CI 1.11–5.16, p=.03) were independent predictors of OS in unclassifiable cases of MDS and MDS/MPN. Consequently, a prognostic scoring system was developed to include these factors. A simple scoring assigned 2 points each to an ANC of ≥8.5k/uL, the presence of peripheral blood blasts, hemoglobin ≤ 11.5g/dL, LDH ≥ 550U/L; and 3 points for age ≥65. This results in three well-separated prognostic groups: (favorable [score:0–3], median OS=67.4 months; intermediate [score:4–6],median OS=28.9 months; and poor [score: ≥ 7], median OS=13.1 months, p<.0001). 34, 21, and 24 patients were placed in these three groups, respectively. In conclusion, clinic-pathologic factors like age, LDH levels, ANC count, Hgb levels and peripheral blood blasts are helpful in predicting survival outcomes in patients with unclassifiable cases of MDS and MDS/MPN disorders. This is the first scoring system devised specifically for patients with this disease subtype. Disclosures: No relevant conflicts of interest to declare.
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Blum, William, Rebecca B. Klisovic, Ramiro Garzon, et al. "Phase 1 Trial of Decitabine and Bortezomib in High Risk Acute Myeloid Leukemia (AML)." Blood 116, no. 21 (2010): 3293. http://dx.doi.org/10.1182/blood.v116.21.3293.3293.
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Abstract Abstract 3293 Background: The hypomethylating agent decitabine has significant activity in AML. We previously demonstrated a novel epigenetic mechanism of action for the proteasome inhibitor bortezomib in AML cells (Liu, Blood 2008). Bortezomib induced hypomethylation of leukemic cells in vitro and in vivo via disruption of the Sp1/NF-kB transcriptional activation complex on the DNA methyltransferase 1 (DNMT1) gene promoter, which resulted in down-regulation of DNMT1 mRNA and protein levels, DNA hypomethylation, and re-expression of otherwise hypermethylated target genes. Based on this, we designed a phase 1 dose escalation trial of decitabine in combination with bortezomib. Methods: Adults with high risk AML who had preserved organ function and ECOG ≤2 were eligible. High risk AML included relapsed/refractory AML or age>60 years with previously untreated disease (if ineligible for or refused standard induction therapy). Patients received decitabine at 20mg/m2 IV daily for days (d) 1–10 of 28 d cycles with dose modification in subsequent cycles based on response and myelosuppression. Bortezomib (given immediately after decitabine) was gradually dose escalated in standard 3+3 fashion from 0.7mg/m2 on d 5 and 8 to the target dose of 1.3mg/m2 on d 5, 8, 12, and 15. Cycles were repeated every 28 d, regardless of count recovery. The plan was to administer 3 cycles if possible before discontinuation due to lack of response. For responding pts, therapy was continued indefinitely. Six additional pts were treated at the recommended phase 2 dose. Dose limiting toxicities (DLT) were assigned for cycle 1 of therapy. Given the high likelihood of infection in this population regardless of therapy, infection was not considered a DLT unless toxicity exceeded that expected with conventional therapy. Results: 19 pts were enrolled with a median age of 69 years (range, 32–83). 12 pts were age>70. 10 pts were previously untreated. Median presenting WBC count was 3,900/uL (range, 1,300-69,200/uL); median bone marrow blast was 34%. Patients received a median of 2 cycles of therapy (range, 1–14 cycles). Two pts received combination therapy beyond 3 cycles of treatment; one received combination for 8 cycles, then decitabine alone for 6 additional cycles, and the other received combination for 4 cycles, then decitabine alone for 6 additional cycles. Dose escalation was halted once the target bortezomib dose was reached; the MTD was decitabine at 20mg/m2 d 1–10 plus bortezomib 1.3mg/m2 d 5, 8, 12, and 15. One DLT of death due to sepsis occurred in dose level 3. Febrile neutropenia and infectious complications were frequent. Death within 8 weeks occurred in 4 pts (21%). Neuropathy attributable to bortezomib, though not meeting DLT criteria, was problematic with repetitive cycles of administration. Specifically, two pts had Grade 3 neuropathy requiring discontinuation of treatment. Responses occurred in 4/10 previously untreated pts: 3 had complete remission (CR) and one had CR with incomplete blood count recovery (CRi). One 84 year old pt with complex karyotype discontinued therapy after one cycle due to fatigue with persistent disease (non-responder). Notably, the pt subsequently had complete count recovery and lived for 14 months with no additional treatment, refusing further marrow evaluation of response. Response durations for the 3 CR were as follows: 12 months, 9 months, and the last patient died in CR after 10 months response duration due to unrelated and preexisting cardiac disease. The CRi lasted 3 months before relapse. Responses occurred in 2/9 relapsed/refractory pts. Both had CRi. Response duration for one patient was only 2 months. The other had allogeneic transplant in first remission 22 months ago before recently expiring in remission with transplant-related complications. In 3/6 responders with abnormal karyotype, two achieved cytogenetic CR. Conclusions: The combination of decitabine and bortezomib was reasonably well tolerated and active in high risk AML. Neuropathy beyond cycle 1 limited prolonged exposure to both agents. Given recent data suggesting equivalent efficacy with weekly dosing of bortezomib in multidrug treatments for myeloma, modification of the bortezomib schedule may facilitate more prolonged exposure to the combination. A phase 2 study of this combination is being planned, with bortezomib modification as noted. Correlative studies are ongoing. NCI U01 CA 76576, NIH/NCI K23CA120708. Disclosures: Blum: Celgene: Research Funding. Off Label Use: decitabine and bortezomib in AML.
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Arnan Sangerman, Montserrat, Helena Pomares, Esther Alonso, et al. "Validation of Low Risk Prognostic Scoring System (LR-PSS) in Patients with Lower Risk IPSS-R Myelodysplastic Syndrome. Results from a Single Center." Blood 134, Supplement_1 (2019): 4270. http://dx.doi.org/10.1182/blood-2019-127901.
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Background: Myelodysplastic syndrome (MDS) therapeutic decisions have been traditionally based on the International Prognostic Scoring System (IPSS) (Greenberg et al, Blood 1997) and IPSS-R (Greenberg et al, Blood 2012). Recently, next-generation sequencing genetics has been incorporated into management of MDS, however its use is limited in routine clinical practice. Current prognostic models do not allow the identification of patients with low risk disease (low or intermediate-1 IPSS) and poor prognosis, who could benefit from an early intervention. Garcia-Manero et al (Leukemia 2008) described a specific prognostic scoring system for this subgroup of patients (LR-PSS) based on age ≥60 years, hemoglobin <10g/dl, platelet count <50k/uL or 50-200k/uL, bone marrow blasts ≥4% and unfavorable cytogenetics (non-del(5q), non-diploid). This LR-PSS score system enables the stratification of low risk MDS patients into 3 different risk categories; interestingly, the third category identifies a subgroup of patients with a median overall survival (OS) similar to that of patients classified as intermediate-2 and high risk IPSS. Besides, the IPSS-R described by Greenberg et al (Blood 2012) has demonstrated a strong prognostic value for OS and LFS as compared to the IPSS when applied to different independent series of MDS patients. The prognostic impact of the LR-PSS has not been analyzed in MDS patients with very low-, low- and intermediate IPSS-R scores. Aim: To analyze the prognostic value of Low Risk Prognostic Scoring System(LR-PSS) in a population of lower risk MDS patients (very low, low and intermediate IPSS-R) analyzing as endpoints overall survival (OS) and leukemia free survival (LFS). Methods: A total of 890 consecutive patients with MDS (01/1992-7/2018) diagnosed at the Catalan Institute of Oncology in Barcelona were included in the study. 539 (60%) had available cytogenetics and therefore, IPSS-R could be assessed. 474 (88%) patients were classified as very low, low and intermediate IPSS-R and were included in the study. Results: 178 (37.6%) patients were classified as very low, 219 (46.2%) low and 77 (16.2%) intermediated IPSS-R risk MDS. Median age at diagnosis was 73 years (range 32-101). 332 (70%) were male. According to the 2008 WHO classification, 2.5% CRDU, 7.4% RA, 42.2% RCMD, 13.7% RAEB‐1, 3.6% RAEB‐2, 26.4% CMML and 4.2% MDS‐U with isolated 5q deletion. At diagnosis, median hemoglobin, platelet and bone marrow blast were 11.6 g/dL (5.5-17.1), 157 x109/L (1-1492) and 2 % (0-17), respectively. 84 (17.7%) patients had unfavorable LR-PSS cytogenetics at diagnosis. Median follow up time for survivors was 5.4 years (range 0.25-23.8). At the time of last follow up, 58.4 % (277) had died and 71 (15%) had progressed to acute myeloid leukemia. When the LR-PSS was applied to the very low, low and intermediate IPSS-R subgroups, three well-differentiated prognostic categories could be identified: 103 patients (21.7%) category 1 (scores 0-2); 330 (69.6%) patients category 2 (scores 3-4) and 41 (8.7%) patients category 3 (scores 5-7) with significant different OS and LFS. Median OS for categories 1, 2 and were 7.1 years (95% CI 4.9-9.2), 5.7 years (95% CI 4.7-6.7) and 2.8 years (95% CI 2.1-3.6), p<0.001 (Figure 1), respectively. Rate of progression to acute myeloid leukemia was 10% (10/99), 15% (48/323) and 27% (11/411) for categories 1, 2 and 3, respectively. Summary/Conclusion: When applied to a low risk (very low, low and intermediate) IPSS-R cohort of MDS population, LR-PSS identifies a subgroup of patients with a significantly worse prognosis who could benefit from an early treatment intervention. Disclosures Sureda: Janssen: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Gilead: Consultancy; Roche: Honoraria; BMS: Consultancy, Honoraria; Sanofi: Consultancy, Honoraria; Takeda: Consultancy, Honoraria, Speakers Bureau.
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Nangia, Julie R., Jamile M. Shammo, Shilpa D. Tilwalli, et al. "Immune Ablation Using Cyclophosphamide without Stem Cell Rescue for Intractable Multiple Sclerosis and Its Variants." Blood 112, no. 11 (2008): 4903. http://dx.doi.org/10.1182/blood.v112.11.4903.4903.
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Abstract Background: Multiple sclerosis (MS) is the most common progressively disabling neurologic disease of young adults worldwide. MS is a cytotoxic T Cell mediated disease with autoimmune-driven destruction occurring most actively in the early stages. Immune suppression with high dose steroids, cyclophosphamide (CTX), cladribine, and mitoxantrone has demonstrated benefit in intractable, more progressive or frequently relapsing patients, both on clinical and MRI parameters. In particular, non-ablative doses of CTX appear to stabilize progressive MS for one year or longer and were most effective earlier in the course of the disease. In aggressive MS deletion of cytotoxic T cells through immune ablation may offer a more durable remission than standard immune suppression. Due to aldehyde dehydrogenase mediated resistance of CD34+ cells to CTX, hematopoietic reconstitution without hematopoietic stem cell rescue is possible and could eliminate the need for stem cell mobilization which has been associated with disease flare and potential re-infusion of T-cells. Objective: To assess the safety and efficacy of immunoablation using CTX without hematologic stem cell rescue for intractable relapsing progressive multiple sclerosis failing standard immune modulation or immune suppression. Patients and Methods: Eight patients (median age = 29, range 24–37, men = 2, women = 6) between January 2005 and July 2008 underwent immunoablation with high dose CTX (HD-CTX) at 50 mg per kg per day intravenously for four consecutive days. Adequate hydration and forced diuresis were implemented to prevent hemorrhagic cystitis. G-CSF was started 6 days after the last dose of chemotherapy at 5 mcg/kg per day until the absolute neutrophil count was &gt; 1000 per UL for two consecutive days. Red cell transfusions were administered to maintain hemoglobin of &gt; 8 gm/dl and platelet transfusions were given to patients with &lt; 10 Th/ul or to patients with active bleeding regardless of their platelet count. Clinical, laboratory, and MRI monitoring was scheduled at 3–6 month intervals over 24 months. Results: Eight patients have been treated with HD-CTX since 2005 and six of these patients have been monitored for more than 2 years. Hematologic complications included grade 4 neutropenia in all patients (duration 9–18 days), grade 4 thrombocytopenia in all patients (duration 3–13 days in 5 patients; 3 patients were discharged prior to platelet recovery), and grade 3 anemia in 6 patients (duration 1–9 days). All 8 patients required platelet transfusion (mean = 3.85 units, range 1–13 units) and 7 patients required PRBC transfusion (mean = 1.625 units, range 0–4 units). Non-hematologic grade 3 or 4 complications included grade 3 neutropenic fever in 7 patients, grade 3 hematuria in 2 patients and CTX-induced cardiotoxity with troponin elevation and infective endocarditis in 1 patient. 1 pt had a dystonic reaction to compazine. All patients have demonstrated improvements ranging from halting progression of MS clinically and radiologically to dramatic reductions of neurologic deficits, except in two patients whose disease reprogressed after 20 months of stability. One of these two patients demonstrated only subclinical disease activity on brain MRI without clinical correlates whereas the other experienced two milder clinical exacerbations. The latter has begun therapy with natalizumab, and the same has been recommended for the former. Given the refractory nature of these patients’ MS prior to therapy, the absence of further disease activity has been remarkable. Conclusions: Immunoablation with HD-CTX without stem cell rescue in patients with intractable MS represents a reasonable treatment option. These patients had significant improvements ranging from amelioration to stabilization of the disease course as well as reduction of disabilities. HD-CTX was tolerable with acceptable side effects and full hematologic recovery without the use of stem cell rescue. This is particularly important in patients with MS because of the associated disease flare and potential re-infusion of T-cells with stem cell mobilization. More data is needed and this clinical trial continues to accrue patients.
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Marco, Ana, Anna Sureda, Pedro Madoz, et al. "Targeting the Poor Mobilizing Population of Patients for An Autologous Transplantation Procedure: A Single Centre Experience." Blood 112, no. 11 (2008): 4136. http://dx.doi.org/10.1182/blood.v112.11.4136.4136.
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Abstract Peripheral blood (PB) has become the major source of hematopoietic stem cells for autologous stem cell transplantation (ASCT) in the last 15–20 years. Nevertheless, there is a subset of patients who do not mobilize adequate numbers of CD34+ cells. There are no clearly established guidelines with respect to second-line mobilization protocols. The aim of this study has been to analyze our experience as a single center with this population of poor mobilizers trying to identify clinical or biological adverse prognostic factors associated to a poor mobilization of progenitor cells into PB, results of second- and third-line mobilization procedures and outcome after the ASCT of those patients who could be autografted in terms of hematological recovery. Poor mobilizing patients were defined as those in whom the apheresis procedure could not be started because of &lt; 10 CD34+ cells/ul or those in which a less than 2 × 106 CD34+ cells/kg could be collected in the first mobilization attempt. From January/2000 to January/2008, 126 patients [70 males/56 females, median age of 53 years (range, 20–70)] out of a total number of 450 patients mobilized for an ASCT in our institution (28%) were identified as poor mobilizers. Clinical diagnosis were: 29 multiple myeloma, 16 Hodgkin’s lymphoma, 48 non-Hodgkin’s lymphoma, 28 acute leukemias and 5 other diagnosis. Median time from diagnosis to mobilization therapy was 19 (range, 3–120) months and median number of chemotherapy lines received before the procedure was 2 (range, 0–5). The first mobilizing protocol was G-CSF alone (5–10 ug/kg/day sc) in 72% of the patients or the combination of chemotherapy plus G-CSF in 28% of the patients. A second mobilization procedure was attempted in 34 patients (28%) with high-doses of G-CSF alone (16–20 ug/kg/day sc) in 24 patients, the combination of G-CSF plus chemotherapy in 8 patients and the combination of G-CSG with stem cell factor (SCF) in 2 patients. A third mobilization attempt was performed in 6 patients (high-doses of G-CSF alone in 4 patients, G-CSF plus chemotherapy in 1 patient and G-CSF plus SCF in 1 patient). Sixty-nine patients (54%) were finally autografted. Median number of CD34+ cells/kg infused were 2.15 × 106/kg (range, 1.01–4.00). Median time to neutrophil recovery after transplantation was 11 days (range, 4–20). Patients with an inadequate mobilization constitute a significant clinical problem (25% of the whole population of patients with an indication of ASCT in our centre). Nevertheless, half of these patients can be rescued for an ASCT procedure with one or two more attempts. Neutrophil recovery after the autologous transplant in those patients undergoing the procedure seems to be similar to that of the group of patients with an adequate first mobilization attempt. New mobilizing agents should be investigated in order to increase the efficacy of the mobilization processes.
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Tanosaki, Ryuji, Kimikazu Yakushijin, Yoshitaka Asakura, et al. "Long-Term Outcome of ATL Patients Who Underwent Reduced-Intensity Stem Cell Transplantation (RIST): Suggested Potent Graft-Versus-ATL and HTLV-1 Effects." Blood 114, no. 22 (2009): 3370. http://dx.doi.org/10.1182/blood.v114.22.3370.3370.
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Abstract Abstract 3370 Poster Board III-258 Although the outcome of patients (pts) with adult T-cell leukemia-lymphoma (ATL) remains poor when they are treated with conventional chemotherapy, we previously showed in a multi-center prospective study that one-third of pts who underwent RIST from a related donor in CR or PR could survive without disease for more than 2 years (Tanosaki R et al., BBMT 2008). In this retrospective study, we reviewed our single-center experience with RIST for ATL pts, focusing on the outcome of those who underwent RIST in non-remission status or who relapsed after RIST. A total of 24 pts underwent RIST from a related donor between 2001 and 2008. The median age was 54 years (range, 44-65). Of the 14 males and 10 females, 19 were acute type and 5 were lymphoma type. Disease status at transplantation was 5 CR, 10 PR, 8 NC and 1 PD. Donors were siblings in 18 and children in 6, including 5 HTLV-1 healthy carriers. HLA in serology was 6/6 in 19 and 5/6 in 5. Stem cell sources were PBSC in 22 and BM in 2. Conditioning regimens were fludarabine (30 mg/m2 iv days -8 to -3) and busulfan (3.2 mg/kg iv days -6 and -5) with (n=8) or without (n=16) rabbit anti-T-lymphocyte globulin (ATG, Fresenius; 2.5 mg/kg iv days -2 and -1). All patients received cyclosporine alone for GVHD prophylaxis. Engraftment was rapid in all 24 pts (neutrophil>500/uL; median 12 days, range 10 -19), with no graft failure. There were 3 non-relapse mortalities; respiratory failure from bronchiolitis obliterans at 21 months (mos), interstitial pneumonitis at 47 mos, and pneumococcal sepsis at 38 mos. Notably, 10 of the 19 pts who were non-CR at RIST survived without disease progression to a median of 53 mos (range, 20 to 85). All of these pts were acute type, and had circulating ATL cells in the peripheral blood (PB) immediately before RIST (average 33% of WBC, range 5-73). Circulating ATL cells decreased to below 5% within 1 mo in 8 pts. A total of 12 pts relapsed within 16 mos; 7 (58%) within 3 mos, and 11 (92%) within 12 mos. Two patients who had relapsed after RIST showed a significant but transient response to the withdrawal of immunosuppression (CR 1, PR 1). Donor lymphocyte infusion was performed in 6 pts without significant benefits. Seven pts who relapsed at a single site, which was confirmed by CT scan or FDG-PET, were treated with local irradiation alone, and 3 whose HTLV-1 proviral load in PB had become negative at relapse survived to 48, 64 and 77 mos; 1 pt required 2 courses of irradiation because of immediate relapse at the margin of the preceding radiation field, and another pt underwent surgical resection of a residual mass since a biopsy revealed a viable lesion at the irradiated site. The 5-year overall and progression-free survival of all pts were 52% (95% CI, 38-66%) and 37% (95% CI, 22-52%), respectively, at a median follow-up of 59 mos (range, 12 to 85) in surviving pts. HTLV-1 proviral load in PB was examined using real-time PCR for tax in 208 samples from 21 evaluable pts, and it became negative at least once in 15 pts (71%), including 1 pt whose donor was an HTVL-1 carrier; proviral load remained negative in 7 pts at a median follow-up of 32 mos (range, 3 to 84). Since HTLV-1 tax is a promising target molecule for identifying the immunological mechanism, HLA-restricted tax-specific CTLs were examined in HLA-A2- and/or A24-positive pts using tax tetramers by taking blood samples periodically after informed consent was obtained from each pt. A total of 80 samples in 13 pts were analyzed. The number of tax tetramer-positive (tax+) cells did not change significantly up to at least 1 year after RIST, while the clinical responses and decrease/disappearance of HTLV-1 proviral load were observed within 3 mos in most cases. An increase in tax+ cells was observed after 1 year in 2 pts who had achieved CR. In conclusion, about half of the acute-type ATL pts with a significant involvement of ATL cells in PB at RIST could survive for a long time in our cohort. ATL pts who relapsed at a single site after RIST still have a chance to be cured with local treatment using irradiation alone or surgical resection with the aid of HTLV-1 proviral load as a marker for minimum residual disease. Since most ATL pts had already become resistant to chemotherapy and the intensity of conditioning was reduced, potent GV-ATL and GV-HTLV-1 effects might have played a key role in disease control. However, tax-specific CTL kinetics did not correlate with either clinical responses or the HTLV-1 proviral load, which suggested that other molecules may be immunologically targeted. Our results might contribute to the establishment of the cure-oriented treatment strategy for ATL pts. Disclosures: No relevant conflicts of interest to declare.