ALBERT

Description: Introduction Recently, reduced-intensity conditioning (RIC) regimens have been used in allogeneic stem cell transplantation (SCT) in which conventional myeloablative conditioning regimens are associated with high rates of non-relapse mortality. Most commonly used RIC regimens are fludarabine/total body irradiation, fludarabine/cyclophosphamide (F/C), fludarabine/busulfan (F/B), and fludarabine/melphalan, with increasing myelosuppressive intensity. Although patients receiving an allogeneic peripheral blood stem cell (PBSC) transplant after a preparative regimen of F/C were reported to develop first T-cell donor chimerism and later myeloid donor chimerism, how chimerism kinetics may be different for these regimens is not fully elucidated. We have retrospectively analyzed early kinetics of engraftment following reduced-intensity SCT and compared the results of F/C and F/B. Patients and methods Data were collected retrospectively on 30 patients who underwent allogeneic SCT after RIC regimens (F/C, n=13; F/B, n=17) between January 2001 and May 2006. F/C patients underwent conditioning a fludarabine and cyclophosphamide regimen consisting of fludarabine 30mg/m2 intravenously daily (days -7 through -2) and cyclophosphamide 30mg/kg intravenously (day -7, -6). F/B patients underwent a fludarabine and busulfan regimen in which busulfan 1mg/kg orally every 6 hours for 2 days (days -5, -4) was substituted for cyclophosphamide. All patients received GVHD prophylaxis with cyclosporine A (from day -1) and short term methotrexate (days +1, +3, +6). Donor chimerism was performed on days 14 and 28 using quantitative polymerase chain reaction of informative polymorphic short tandem repeat regions. Results On day 14, donor chimerism of myeloid cells was 25.8% and 68.1% in patients with F/C and F/B, respectively (p=0.023). On the contrary, donor chimerism of T-cells was 71.4% and 34.3% in patients with F/C and F/B, respectively (p=0.024). Similar results were obtained on day 28. Myeloid donor chimerism was 72.0% and 98.6% (p=0.002), and T-cell donor chimerism was 94.5% and 69.3% (p=0.006) in patients with F/C and F/B, respectively. Discussion Engraftment kinetics of allogeneic SCT after RIC regimens depend on the intensity of pretransplant chemotherapy, the intensity of the conditioning regimens, and the graft composition. Unfortunately, our analyses were retrospective, and the majority of stem cell source used in F/C was PBSC in contrast to bone marrow in F/B. However, even with PBSC, T-cell donor chimerism was previously reported to be delayed in F/B conditioning compared to myeloid donor chimerism. Our results clearly demonstrated that chimerism kinetics is strikingly different between F/C and F/B and suggested that not only the intensity but also the impact on chimerism of RIC regimens should not be considered equivalent.

Description: Abstract 1464 Background: Retrospective studies have shown that AYA with ALL treated with pediatric protocols have better outcomes than similarly aged patients with adult protocols, but prospective studies comparing AYA with pediatric schedules are scarce. So, we conducted a phase II multicenter study (JALSG ALL202-U) in collaboration with the Japan Association of Childhood Leukemia Study (JACLS) to determine the efficacy and safety of pediatric type therapy (JACLS ALL-02-HR). Methods: From June 2002 to September 2009, patients (age range 16–24 years) with previously untreated ALL (excluding Philadelphia-positive ALL and mature B-cell ALL) were consecutively registered in this study. For patients with t (4; 11), allogeneic stem cell transplantation (HSCT) was recommended during their first complete remission (CR), if donors were available; whereas for patients without t (4; 11), there were no criteria for choosing HSCT. This protocol consisted of induction therapy (pre-phase with oral corticosteroids and 5-drug induction), consolidation phase including 1) consolidation therapy, 2) sanctuary therapy with two cycles of high dose MTX, 3) reinduction therapy, 4) reconsolidation therapy and 2-year maintenance therapy. Intrathecal chemotherapy was administered during each cycle. In comparison with the former JALSG ALL-97 adult protocol, the pediatric-type therapy showed an increase in cumulative dose of CPM (1.5-fold), VCR (1.2-fold), L-asp (18-fold) and MTX (3.7-fold), respectively. As for the intrathecal chemotherapy, the duration was longer (ALL97; 4 to 21 week, ALL202; 1 to 94 week) and the frequency was increased from 8 to 15 times. Results: There were 138 eligible patients: median age was 19 years old and 56% were male. Of the eligible patients, 134 patients (97.1%) achieved CR. The estimated the 4-year OS rate was 74% and 4-year DFS rate was 71%, respectively. Compared with previous JALSG ALL-97 study, CR rate (97.1% ALL202, 84% ALL97; p=0.01), 4-year DFS rate (fig 1, 71% ALL202, 46% ALL97; p=0.0001) and 4-year OS rate (fig 2, 74% ALL202, 46% ALL97; p=0.0002) were significantly higher in this study. During induction therapy, major grade III-IV adverse events (AEs) were FN, DIC, pancreatitis and AST/ALT. The frequency of FN was higher with ALL202-U protocol (43%) than with ALL-97 protocol (12%). During consolidation phase and maintenance therapy, the most common toxicity was FN. The treatment duration during induction therapy and consolidation phase was longer than planned. In comparison with the outcome of JACLS ALL-02-HR protocol, grade 3 to 4 AEs were similar. Conclusion: This pediatric-type therapy was very efficient, yielding a 97.1% CR rate, 71% 4-year DFS and 74% 4-year OS in AYA patients. The protocol was tolerable, but FN and treatment prolongation were observed. Grade 3 to 4 AEs were similar to pediatric group. The data reported here were collected at the time of interim analysis. The latest data including AEs are currently being reviewed and will be disclosed at the presentation. Disclosures: No relevant conflicts of interest to declare.

Description: For patients with malignant hematological diseases that relapse after allogeneic hematopoietic stem cell transplantation (HSCT), a second HSCT is thought to be a curative option. A second donor is usually searched for due to HLA discrepancy between the graft and the host. However, it is unclear whether HLA discrepancy between the graft and the first donor has an impact on the outcome of second HSCT. To address this issue, we focused on second HSCT patients who had received first HSCT from an HLA-mismatched (MM) donor and compared the effects of HLA discrepancy between graft and first donor with those between graft and host. We retrospectively analyzed 646 patients receiving second HSCT between 1994 and 2016 after an initial HLA-MM transplantation. With regard to the graft versus host results, the one-allele mismatch (1 MM) group (relative risk [RR], 1.88; 95% confidence interval [CI], 0.79-4.45; p=0.163) and more than one-allele mismatch group (≥ 2 MM) (RR, 1.84; 95% CI, 0.75-4.51; p=0.182) had higher risks of grade III-IV acute GVHD compared to the HLA-matched (0 MM) group, although the results were not significant. In contrast, almost no difference in risk of acute GVHD was found among the 0, 1, and ≥ 2 MM group with respect to graft vs. first donor. Furthermore, with regard to graft vs. host, the ≥ 2 MM group showed a significantly higher risk of treatment-related mortality (TRM) (RR, 1.90; 95% CI, 1.04-3.50; p=0.038) compared to the 0 MM group. In contrast, the risk of relapse was slightly lower in the ≥ 2 MM group (RR, 068; 95% CI, 0.44-1.06; p=0.086). Consequently, no significant difference in OS was found among the three groups. In the analysis of each HLA allele MM, B allele MM between graft and host was associated with an increased risk of grade III-IV acute GVHD (RR 2.87; 95% CI, 1.42-5.79; p=0.003) and DR allele MM between graft and host was associated with a lower risk of relapse (RR, 0.75; 95% CI, 0.58-0.95; p=0.018) and higher risk of TRM (RR, 1.44; 95% CI, 1.03-2.00; p=0.033). In contrast, with regard to graft vs. first donor, there were no significant differences in relapse, TRM, or OS among the three groups, and also analysis of each HLA allele MM indicated no associations with relapse, TRM, or OS. These findings suggested that HLA discrepancy between graft and host, rather than between graft and first donor may induce transplant-related immunological responses in second HSCT leading to an increase in TRM. In conclusion, HLA-MM donor is an option after initial HLA-MM transplantation, however, TRM remains a challenge, particularly with a ≥ 2 MM donor regarding to graft versus host. In this study, the biological effects of HLA discrepancy between the graft and the first donor on the outcome appeared negligible, and our findings shed light on the role of nonhematopoietic APCs on transplant-related immunological responses. Figure. Figure. Disclosures Nakamae: Otsuka Pharmaceutical Co., Ltd.: Consultancy, Honoraria, Research Funding. Ichinohe:Mundipharma: Honoraria; Eisai Co.: Research Funding; Ono Pharmaceutical Co.: Research Funding; Alexion Pharmaceuticals: Honoraria; Zenyaku Kogyo Co.: Research Funding; Kyowa Hakko Kirin Co.: Research Funding; CSL Behring: Research Funding; Novartis.: Honoraria; Takeda Pharmaceutical Co.: Research Funding; Taiho Pharmaceutical Co.: Research Funding; Chugai Pharmaceutical Co.: Research Funding; Astellas Pharma: Research Funding; Repertoire Genesis Inc.: Research Funding; Sumitomo Dainippon Pharma Co.: Research Funding; Bristol-Myers Squibb: Honoraria; Celgene: Honoraria; JCR Pharmaceuticals: Honoraria; Janssen Pharmaceutical K.K.: Honoraria; Pfizer: Research Funding; Nippon Shinyaku Co.: Research Funding; MSD: Research Funding; Otsuka Pharmaceutical Co.: Research Funding. Kanda:Ono: Consultancy, Honoraria, Research Funding; Shionogi: Consultancy, Honoraria, Research Funding; Nippon-Shinyaku: Research Funding; Astellas: Consultancy, Honoraria, Research Funding; Kyowa-Hakko Kirin: Consultancy, Honoraria, Research Funding; Taiho: Research Funding; Pfizer: Research Funding; Taisho-Toyama: Research Funding; MSD: Research Funding; Novartis: Research Funding; Tanabe-Mitsubishi: Research Funding; Chugai: Consultancy, Honoraria, Research Funding; Otsuka: Research Funding; Dainippon-Sumitomo: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria, Research Funding; Bristol-Myers Squibb: Consultancy, Honoraria; Eisai: Consultancy, Honoraria, Research Funding; Sanofi: Research Funding; CSL Behring: Research Funding; Asahi-Kasei: Research Funding; Celgene: Consultancy, Honoraria; Mochida: Consultancy, Honoraria; Alexion: Consultancy, Honoraria; Takara-bio: Consultancy, Honoraria.

Description: Abstract 1902 Several clinical and experimental studies have reported that a recently developed intra-bone marrow (IBM) stem cell transplantation (SCT) technique gives high rates of engraftment and is associated with a low incidence of acute graft-versus-host disease (GVHD). Idiopathic pneumonia syndrome (IPS) is a significant cause of mortality and remains a major obstacle after allogeneic SCT. In the present study, the extent of IPS after IBM-SCT was compared with that after conventional intravenous SCT (IV-SCT) using a lethally irradiated B6(H-2b) into F1 (H-2b/d) mouse IPS model. Compared with IV-SCT, IBM-SCT significantly improved the clinical GVHD score and reduced total and CD3+ T cell numbers in bronchoalveolar lavage fluid (9.6± 3.5 vs. 21.3 ± 0.5 x104/ml; p 〈 0.05). Histopathological examination of lung tissue at 6 weeks post-SCT showed significantly reduced IPS pathology in mice that underwent IBM-SCT. To explore the mechanisms of the reduction in IPS pathology in mice that underwent IBM-SCT, we monitored the in vivo distributions of infused donor cells and compared them between mice that underwent IBM-SCT versus IV-SCT. Recipient mice were imaged at different time points (1, 2, 3, and 6 h, and 1, 2, 3, and 5 days), using a lethally irradiated luciferase-expressing transgenic FVB/N (FVB/N luc+)(H-2q) into BALB/c (H-2d) mouse model. In vivo bioluminescence imaging (BLI) analysis revealed that the majority of injected donor cells were trapped in the lung 1 h after IV-SCT. In contrast, almost all donor cells were localized in the injected limbs 1 h after IBM-SCT, and significantly fewer cells had reached the lung (3.1± 0.7 vs. 16.7± 1.1 x105 photons/sec/animal, IBM-SCT vs. IV-SCT, p 〈 0.01; Figure). After syngeneic (FVB/N luc+ into FVB/N) SCT, the majority of the injected cells were also trapped in the lung 1 h after IV-SCT, and a similar difference was observed in donor cell distribution in the lung after IV-SCT versus IBM-SCT (2.4± 0.6 vs. 11.6± 1.3 x105 photons/sec/animal; p 〈 0.01). These results suggest that initial cell localization to the lung is dependent on the SCT method. At 2 days post-SCT, we examined the profiles of chemokines produced locally in the lung (CCL2, CCL3, CXCL1, CCL5, and CCL8). The mRNA expression of CC chemokines, especially CCL2, was more strongly induced in the lung after allogeneic IV-SCT than after allogeneic IBM-SCT (0.098 ± 0.020 vs. 0.020 ± 0.003 units/GAPDH mRNA; p 〈 0.05). A similar difference was observed between mice that underwent syngeneic IV-SCT and syngeneic IBM-SCT, suggesting that increases in chemokine levels in the lung early post-SCT are also dependent on the SCT method. At 5 days post-syngeneic SCT, BLI analysis revealed that no difference was observed in donor cell distribution in the lung after IV-SCT versus IBM-SCT (4.8± 1.1 vs. 4.6± 2.5 x107 photons/sec/animal; p =0.94). On the other hand, the BLI signals dramatically increased in the lungs of mice that had undergone allogeneic IV-SCT after day 2 post-SCT and there was a significant difference in the BLI signals between IV-SCT and IBM-SCT mice at 5 days post-SCT (50.9± 6.6 vs. 16.0± 6.2×107 photons/sec/animal; p 〈 0.05). These results suggest that increases in chemokine levels in the lung at day 2 post-SCT lead to increases in the allogeneic response in the lung. In summary, we have shown that the initial localization of donor cells to the lung and increases in lung chemokine levels are dependent on the SCT method. The targeting of donor cell trafficking to the lung may be a promising strategy for preventing IPS, and IBM-SCT may reduce IPS after allogeneic SCT. Disclosures: No relevant conflicts of interest to declare.

Description: Background and Objectives: Thrombotic microangiopathy (TMA) after hematopoietic stem cell transplantation (SCT) is a devastating complication of SCT and lacks optimal managements with a high mortality. Its pathogenesis is not well understood but suggested that endothelial toxicity caused by chemoradiotherapy, infections, immunosuppressive drugs, graft-versus-host-disease (GVHD) and infections have been thought to play important roles. Recently recombinant human soluble thrombomodulin (rTM) was reported to be a safe and efficient treatment of disseminated intravascular coagulation for hematological malignancies. rTM which contains active extracellular domain of thrombomodulin, inactivates coagulation and the thrombin-rTM complexes activates protein C to activated protein C (APC). APC in activates factors Va and VIIIa with protein S, and subsequently lead to further thrombin formation. And, also rTM possesses cytoprotective effects against calcineurin inhibitor induced endothelial cell damage, anti-inflammatory activity such as decrease of high-mobility group box 1 protein, IL-6 and TNF-a. Hence we compared the efficacy of rTM with TMA to other conventional treatments. Patients and Methods: Of 223 patients who had received SCT in our institute from January 2009 to March 2014, 16 patients diagnosed as TMA after allogeneic stem cell transplantation were identified from database. Diagnosis of TMA was based on the Bone Marrow Transplant Clinical Trials Network (BMT-CTN). Patients treated with rTM as a first-line therapy were categorized as rTM group and treated with other therapies as a first-line therapy were as control group. Results: TMA occurrence was total 16 cases (7.2%). rTM group had 9 patients and control group had 7 patients. rTM group had male dominant (M/F 8/1 vs. 1/6) compared to control group. Both group showed similar age, disease distribution (rTM; 2 Leukemia, 5 Lymphoma and 2 ATLL vs. control; 3 Leukemia, 2 CML-BC and 2 ML), disease risk (rTM; 2 standard (1-2 CR or MDS) and 7 high vs. control; 7 high), hematopoietic cell transplantation specific comorbidity index, type of donor source (rTM; 5 related PBSC and 4 unrelated BM vs. control; 4 related PBSC and 3 unrelated BM), HLA compatibility (rTM; 4 haplo-identical donor vs. control; 3 haplo), conditioning regimen (rTM; 8 reduced intensity vs. control; 5 reduced intensity), GVHD prophylaxis (rTM; 5 CyA/Tac and short MTX, 4 Tac/ATGmPSL vs. control; 5 CyA/Tac and short MTX, 2 Tac/ATGmPSL) and year of transplant. Median onset of TMA in rTM group and control group were on day 24.5 (16-274) and day 72 (7-338) (p=0.13) post SCT, respectively. Compared with control group, rTM group revealed significantly superior overall survival after the onset of TMA (Figure1, p=0.043). Seven patients (77.8%) of rTM group recovered from TMA, while no patients recovered in control group. Acute GVHD were occurred in 5 cases of rTM group and in 4 cases of control group (p=0.29). Grade II to IV acute GVHD were occurred in 3 of rTM group and in 4 cases of control groups (Figure 2, P=0.66). Leading causes of death were 4 GVHD of 5 cases in rTM group and 3 TMA of 7 cases in control group. Both group had no lethal hemorrhagic event. Conclusion; The use of rTM in TMA improved overall survival after the onset of TMA in this retrospective small number analysis. rTM reduced TMA mortality but GVHD was still a major cause of death in TMA survivors. Larger prospective studies are warranted to fully evaluate the efficacy of rTM. Figure 1 Figure 1. Figure 2 Figure 2. Disclosures No relevant conflicts of interest to declare.

Description: Abstract 4487 Chronic graft-versus-host disease (cGVHD) remains a major cause of late death and morbidity after allogeneic hematopoietic cell transplantation, and the treatment of cGVHD remains challenging. All-trans retinoic acid (ATRA), a potent vitamin A derivative, can regulate immune responses. Synthetic retinoid Am80, which shows biological activity approximately 10 times more potent than that of ATRA by binding to RARα and RARβ, but not RARγ, also reduces the severity and progression of immune disease models, including those for contact dermatitis, collagen-induced arthritis, allergic encephalomyelitis, and atherosclerosis. We hypothesized that the administration of ATRA or Am80 could modulate cGVHD. BALB/c (H-2d) mice were subjected to sublethal irradiation and injected with 8 × 106 T-cell-depleted bone marrow cells and 8 × 106 spleen cells from major histocompatibility complex-matched, multiple minor histocompatibility antigen-mismatched B10.D2 (H-2d) mice. Then, the mice were given oral ATRA (200 μg/body), Am80 (1.0 mg/kg body weight), or vehicle daily, beginning from day 0. ATRA slightly decreased the clinical cGVHD score, whereas Am80 significantly reduced the score (Table). When administered daily, Am80 decreased the clinical score beginning from day 21, as in a treatment setting (data not shown). Histopathological examination of the skin showed significantly reduced GVHD pathology in recipients of Am80 (Table). Flow cytometry analysis of the peripheral draining lymph nodes on day 16 showed significant reductions in IFN-γ+, IL-17+, and Foxp3+ cells in Am80-treated recipients compared to controls (Table), whereas no reduction in IL-13+ cells was observed. Cytometric bead arrays and enzyme-linked immunosorbent assays (ELISA) revealed decreased levels of the cytokines IFN-γ, IL-17, TNF-α, and IL-6 in the supernatant of peripheral lymph nodes from Am80-administered recipients (data not shown). Real-time RT-PCR of ears from these recipients on day 21 showed that the administration of Am80 reduced the expression of Foxp3 and TGF-β (Table and data not shown). Therefore, the administration of retinoids ameliorates cGVHD by reducing Th1 and Th17 inflammatory cytokines and the fibrosis factor TGF-β. Thus, treatment with retinoids may be effective for prophylaxis and treatment of cGVHD. Disclosures: No relevant conflicts of interest to declare.

Description: Introduction: The creatinine clearance rate (Ccr) is a more accurate indicator of renal function than serum creatinine. There remains a paucity date of prognostic value of mild to severe renal impairment calculated by Ccr for patients who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT). Herein, we evaluated the transplant outcome of patients with mild to severe renal dysfunction and compared to those without renal dysfunction. Patients and methods: A total of 186 patients (118 male and 68 female; median age, 50 years; range 15-70 years) with hematological malignancies who underwent first allo-HSCT in our institution between 2008 and 2015 were retrospectively collected from medical records. Transplant outcomes were compared with regard to renal function before allo-HSCT. The threshold of renal dysfunction was 60 ml/min (Ccr 〈 60) calculated by Ccr. Overall survival (OS) was estimated by Kaplan-Meiyer. Engraftment rate, cumulative incidence of relapse (CIR), non-relapse mortality (NRM), acute graft-versus-host disease (aGVHD), chronic GVHD and acute kidney injury (AKI) within 100 days after alo-HSCT were calculated using Grayfs method. Factors associated with significance (p 〈 0.1) on univariate analyses were subjected to multivariate analysis. Multivariate analysis was performed using the Cox proportional hazards regression model for OS and Fine-gray proportional hazard regression model for NRM and CIR. Results: Among the 186 patients, renal dysfunction (Ccr 〈 60) was observed in 30 patients (16%) before conditioning regimen. We observed no significant difference between Ccr 〈 60 group and Ccr ≥ 60 group in terms of clinical characteristics including gender, HLA disparity, stem cell source, disease risk, comorbidity, performance status at allo-HSCT and GVHD prophylaxis. However, compared to Ccr ≥ 60 group, patients with Ccr 〈 60 group were significantly older (p = 0.0008), lower estimated GFR (p 〈 0.0001), higher serum creatinine (p 〈 0.0001), more cases diagnosed non-Hodgkin lymphoma (p = 0.0003) and more cases received reduced intensity conditioning regimen (p = 0.002). All but one patient with CCr 〈 60 group achieved neutrophil engraftment median 15 days (range, 9-24) after transplantation (engraftment rate 97%) and 1 patient died before engraftment. Regarding the transplantation outcome, no significant difference was observed in OS, CIR, NRM, aGVHD, cGVHD and AKI after allo-HSCT between 2 groups (Ccr 〈 60 vs. CCr ≥ 60; 2-year OS, 45% vs. 49%, p = 0.6, 2-year CIR, 41% vs. 30%, p = 0.3, 2-year NRM, 23% vs. 26%, p = 0.6, day-100 AKI, 57% vs. 63%, p = 0.6, Figure 1). Multivariate analysis demonstrated that Ccr 〈 60 before allo-HSCT was not an independent prognostic factor for OS, CIR and NRM (Table 1). To investigate the impact of mild to severe renal failure on the transplant outcome, we next explored the clinical results of 30 patients with renal failure more in detail. Of them, 13 patients (43%) had estimated GFR 〈 60 ml/min/1.73m2 and only 5 patients (17%) had a serum creatinine level 〉 1.2mg/dl. Two patients (7%) developed end-stage renal failure requiring dialysis. Eighteen patients (60%) died at a median 194.5 (range, 15-859) days after allo-HSCT. Relapse of the primary disease was the leading cause of death (n=9) and cause of NRM were infection (n=3), veno-occlusive disease (n=2), respiratory failure (n=2), cGVHD (n=1) and central nervous system complication (n=1). No patients died from renal failure. All patients with severe renal dysfunction defined as Ccr 〈 40ml/min (Ccr; 13.4 ml/min, 36 ml/min and 36 ml/min) died 17, 15 and 72 days after allo-HSCT, respectively. Conclusion: Our cohorts with total 186 patients underwent allo-HSCT showed that mild renal dysfunction defined as Ccr 〈 60 ml/min before allo-HSCT did not affect adversely for transplant outcomes. In line with previous reports, Ccr could detect renal impairment that could not identified by GFR estimated from serum creatinin. On the other hand, no patients with severe renal dysfunction could survive after allo-HSCT. To our knowledge, the current study includes the largest number of patients with Ccr 〈 60ml/min. However, our small experience clearly desires larger series patients for evaluating the real impact of mild to severe renal dysfunction before transplantation. Disclosures No relevant conflicts of interest to declare.