ALBERT

Description: Introduction A relative increase in classical monocyte fraction (cMo, CD14++CD16-) over 94% of total peripheral blood monocytes, as measured by flow cytometry, distinguishes a CMML from a reactive monocytosis with a 94.1% specificity and a 92.8% sensitivity (Selimoglu-Buet, 2015; Talati, 2017; Patnaik, 2017; Selimoglu-Buet, 2017; Hudson, 2018). This phenotype is independent of the absolute monocyte count, WHO subtype of CMML, its dysplastic (MD) vs proliferative (MP) feature and its mutational background. The limitation of this diagnostic tool is the changes in monocyte subset repartition induced by an associated inflammatory disease that increase the fraction of intermediate monocytes (iMo, CD14++CD16+), leading to underestimation of cMo accumulation (Selimoglu-Buet, 2017). The present study explores the prognostic significance of cMo accumulation in CMML. Patients and methods Among CMML patients (diagnosis according to 2016 WHO criteria) included in our previous studies, we selected patients diagnosed from June 2012 to March 2017 in four centers in which follow-up was actualized in June 2019. Disease was classified according to WHO 2016 (CMML-0, -1, -2 and MP vs MD subtypes). When possible, the CMML Prognostic Scoring System (CPSS) was calculated. Peripheral blood flow cytometry data were reanalyzed in a blind fashion by a skilled operator. Inflammatory CMML were defined by a cMo percentage

Description: Background Unrelated cord blood transplantation (UCBT) after reduced intensity conditioning regimen (RIC) has extended the use of cord blood in elderly patients and those with co-morbidities without an HLA identical donor, although relapse post transplant remains a concern in high risk AML patients. HLA incompatibilities between donor and recipient might enhance Natural Killer (NK) cell alloreactivity after allogeneic hematopoietic stem cell transplantation (HSCT). We previously observed that the quality of NK cell reconstitution was impaired after haploidentical HSCT, impacting on graft versus leukemia (GvL) effect, but was preserved after UCBT in a small cohort of patients. Methods To evaluate RIC-UCBT in patients with acute myeloid leukemia (AML), a prospective phase II multicentric trial was conducted in France, whose primary objective was to show a reduction in non-relapse mortality (NRM) from 40% (based on registry data) to 20%. Seventy-nine patients were enrolled for a de novo or secondary AML in complete remission (CR). The conditioning regimen consisted of cyclophosphamide (50mg/kg) + fludarabine (200mg/m2) + total body irradiation (2Gy), CsA +MMF as GVHD prophylaxis and GCSF from day +1. Patients were enrolled in 23 centers from October 2007 to September 2009. Engraftment rate was 87 % at day+60. At 2 years, overall survival, incidence of relapse and LFS were respectively 44%, 46% and 35%. Peripheral blood samples were collected following UCBT in order to realize an extensive phenotypic and functional study of NK cells. Studies were started at 1 month (M1) post UCBT with available samples for 62 out of the 69 included patients, and were compared to 20 healthy donors and 15 cord blood (CB). Results Total CD3+ T-cells were 117 /mm3 at M1 (range 0-934), and 465 /mm3 at M3 (range 0-2917). CD19+ B-cells were 36/mm3, (range 0-524) and 342/mm3 (range 0-2990) at M1 and M3 respectively. NK cell recovery was prompt, representing 47% of the total lymphocyte population at M1 (186 CD3-CD56+ NK cells/mm3), 30% at M3 (239/mm3; range 2-767) and decreasing to normal rate at M6 (20% of lymphocytes). At M1 post-UCBT, NK cells exhibited high rate of CD56bright, NKG2A, and KIR2DL4 associated with a decreased expression of CD8 and CD161, compared to CB and healthy donors. These immature characteristics were transient and return to normal value from M3 or M6 post-UCBT. Interestingly, we also observed a significant increased expression of the activation markers CD69, and HLA-DR during the whole period of the study, compared to CB and healthy donors, which probably reflects a persistent proliferation state of the NK cells. On the other hand, NK cells post-UCBT were indistinguishable from CB and healthy donors control samples for other receptor tested such as NKp30, NKp46, NKp80, and NKG2D. Notably, Expression of KIR2DL1 was decreased at M1 and M3 but reached similar values to controls at M6, whereas, KIR3DL1 was increased during the whole study. To determine the significance of these phenotypic features, we assessed polyfunctional ability of NK cells following UCBT by a combined analysis of the degranulation (CD107a), and the production of IFN-γ and TNF-α. This study reveals that NK at M1 post-graft exhibited a transient higher ability to produce IFN-γ than healthy donors (p

Description: We aimed to determine whether outcome of HSCT from an unrelated donor has improved over time for patients with severe acquired aplastic anemia (SAA) and, if so, to determine whether improvement resulted from changes in patient selection, changes in transplantation technique, or both. We thus analyzed the outcome of 89 patients (median age 17 years, range 0–52) who received such transplantations between 1989 and 2004. We compared two cohorts of patients transplanted within two successive time-periods (1989–1998 and 1999–2004) associated with probabilities (± 95% confidence interval) of 5-year survival significantly different: 29% ± 7% and 50% ± 7%, respectively (P

Description: Background: Invasive fungal infections (IFIs) incur significant morbidity and mortality among neutropenic patients with hematological malignancies. Prevention and early antifungal treatment include prophylaxis where antifungal agent is started along with neutropenia; empirical therapy where antifungal agent is initiated in persistently febrile patients at least four days after neutropenia onset; preemptive therapy where antifungal agent is initiated later for a suspected IFI based on clinical symptoms, lung imaging, or biological markers. Without data from clinical trials comparing antifungal strategies, determining an optimal antifungal strategy for these patients is challenging. Objective: To determine the cost-effectiveness of all possible antifungal strategies. Target Population: Adult patients with hematological malignancies in induction chemotherapy at high risk for IFIs. Interventions: Prophylaxis with either fluconazole or posaconazole, empirical strategy, and preemptive strategy with fist-line antifungal therapy being amphotericin B, liposomal amphotericin B or caspofungin (Table). Design: Cost-effectiveness decision model. The study cohort encountered seven successive chance nodes during hospital stay: having fever; in those having fever, IFI incidence; Aspergillus or Candida species among IFI; admission in intensive care unit; dying from IFI or underlying hematological malignancy; in patients alive, having severe nephrotoxicity as defined by a twofold increase in baseline serum creatinin; dying from severe nephrotoxicity. Antifungal strategies modified the probabilities of IFI and severe nephrotoxicity that depended on both the duration and the type of antifungal drugs administered. Data Sources: PREVERT trial1, effectiveness data published to December 2007, probabilities of ICU admission and in-hospital mortality according to the occurrence of IFI in the French DRG database, life expectancy of French patients with acute myeloid leukemia, and actual French hospitalization costs (2007 euros). Time Horizon: Lifetime. Perspective: Societal. Outcome Measures: Incremental cost (euros) per discounted life-year saved averaged from 100 samples of 1000 patients (second-order probabilistic Monte Carlo simulations). Results (Table): Fluconazole prophylaxis followed by ampho-B treatment was the cheapest antifungal strategy. Posaconazole prophylaxis followed by ampho-B was nearly cost-effective (59,610 € per discounted year of life gained). Other strategies were either dominated or beyond usual societal thresholds of what may be worth it. Similar results were found in sensitivity analyses among plausible ranges. Conclusions: As compared to previous studies showing that new antifungal drugs were cost-effective within a single strategy, empirical and preemptive antifungal strategies were dominated by prophylaxis strategies. Table: Incremental cost-effectiveness ratio of antifungal strategies in high-risk neutropenic patients Total cost (2007 euros) Years of life gained ICER IFI (%) Aspergillus (%) Nephro-toxicity (%) Antifungals’ cost (2007 euros) Fluconazole then amphoB 35606 2.3448 -- 3.81% 2.61% 4.22% 909 Fluconazole then L-amphoB 36025 2.3457 (extended dominance) 3.81% 2.61% 3.67% 1430 Empirical amphoB 36033 2.3433 (dominated) 3.38% 2.3% 5.98% 1914 Posaconazole then amphoB 36065 2.3525 59,610 € 1.2% 0.81% 3.67% 2646 Preemptif amphoB 36160 2.3449 (dominated) 3.89% 2.67% 4.42% 1247 Posaconazole then L-amphoB 36389 2.3532 462,857 € 1.2% 0.81% 3.21% 3055 Fluconazole then Caspo 36557 2.3459 (dominated) 3.81% 2.61% 3.53% 1985 Preemptif L-amphoB 36616 2.3455 (dominated) 3.89% 2.67% 3.84% 1809 Posaconazole then Caspo 36828 2.3533 4,390,000 € 1.2% 0.81% 3.13% 3509 Empirical L-amphoB 37308 2.3462 (dominated) 3.38% 2.3% 4.39% 3239 Preemptif Caspo 37346 2.3458 (dominated) 3.89% 2.67% 3.55% 2597 Empirical Caspo 39123 2.3473 (dominated) 3.38% 2.3% 3.47% 5080

Description: Purpose: The use of rituximab, a chimeric monoclonal antibody to CD20, has led to significant improvement in the treatment of B-cell non-Hodgkin's lymphoma and mature B-cell ALL. CD20 is expressed in 30 to 50% of adult BCP-ALL patients. Although some single arm studies suggested that adding rituximab to chemotherapy could improve the outcome of these patients, no randomized study has been reported so far. Methods: To evaluate the potential benefit of adding rituximab, we conducted a multicenter randomized trial comparing the pediatric-inspired GRAALL protocol to the same regimen plus rituximab, in patients aged 18-59 years old with newly diagnosed CD20-positive Ph-negative BCP-ALL enrolled in the GRAALL 2005 trial. CD20 positivity was defined as expression of CD20 in more than 20% of leukemia blasts. Rituximab (375 mg/m2) was given during induction (day 1 and 7), salvage reinduction when needed (day 1 and 7), consolidation blocks (6 infusions), late intensification (day 1 and 7) and first year of maintenance (6 infusions) for a total of 16 to 18 infusions. Allogeneic stem cell transplantation (SCT) was offered in first complete remission (CR) to patients with one or more conventional high-risk criteria and a donor. The primary study objective was event-free survival (EFS). A study sample size of 220 patients was estimated in order to detect a 20% gain in EFS at 2 years (two-sided test, power 85%, type 1 error 5%). A sensitivity analysis was performed after censoring patients allografted in first CR at transplant time. This trial was registered at http://www.clinicaltrials.gov as #NCT00327678. Results: From 2005 to 2014, 220 patients from 56 centers were randomized. Eleven patients had non-eligibility criteria (n=5 Ph+ ALL; n=3 CD20-negative ALL; n=1 HIV infection) or withdrew their consent (n=2) and were accordingly excluded from this modified ITT analysis that dealt with 209 patients (105 in the rituximab arm and 104 in the control arm). Median age was 40 years. Both randomization arms were well balanced for pretreatment characteristics including age, ECOG status, WBC, and central nervous system (CNS) involvement (6% of the whole cohort). After induction ± salvage reinduction, CR rate was 92% and 91% in rituximab and control arm, respectively. In patients who reached CR after first induction and were evaluated for Ig/TCR minimal residual disease level (MRD), the rates of patients with MRD

Description: Background: Survival after HSCT from HLA-identical siblings is inferior in SAA patients 30 years or older as compared with younger patients. In order to improve survival in patients 〉30 years, the use of a less toxic regimen including reduced doses of chemotherapy in combination with ATG, while adding fludarabine, might be an option to explore with the aim to reduce transplant-related mortality. In the unrelated donor setting, we previously showed that a regimen combining fludarabine, ATG, and low-dose cyclophosphamide (CY) provided encouraging disease-free survival in 38 patients (Bacigalupo et al, Bone Marrow Transplant 2005). Patients and Method: In order to evaluate the toxicity profile, engraftment potential, and efficiency of HLA-identical HSCT using such fludarabine-based conditioning regimen, we conducted this study from the EBMT-SAA database, focussing on patients older than 30 years. From November 1996 to February 2005, 45 patients from 27 centres (median age 49 years, range 31–66 years) received HSCT for idiopathic SAA (n=40), or PNH clone-associated SAA (n=5). HSCT was performed either as first-line treatment (n=29), or after failure of ATG/ciclosporine (CsA) (n=10), or failure of a first allogeneic HSCT (n=6). The median interval between diagnosis and HSCT was of 10 months (range 1–350). Various fludarabine-based conditioning regimens were used (see Table), incorporating ATG +/− chemotherapy in the majority of patients (40 out of 45). We analyzed separately the outcome of patients receiving the combination of fludarabine, ATG and low-dose (500/μL) recovery occurring at a median of 16 days after transplant. Acute GVHD occurred in 16 patients with a maximum grade II in 11 patients and grade III-IV in 5. Among 33 evaluable patients, 11 developed chronic GVHD (extensive in 6). With a median follow-up of 21 months, the Kaplan-Meier overall probability of survival was of 54% ± 1%. Infections (n=5) and multi-organ failure (n=3) were the primary causes of death. In univariate (UV) and multivariate (MV) analyses incorporating patient- and transplant-related variables, the only factor significantly associated with better outcome was the type of conditioning, the fludarabine/ATG/low-dose CY combination providing a 77% ± 1% probability of survival versus 24% ± 1% with other regimens (p=.02 in UV and MV analyses). Conclusion: Reduced intensity fludarabine-based conditioning regimen is feasible in SAA patients over the age of 30 and produces encouraging survival, especially when using a fludarabine, ATG and low-dose CY combination. A prospective trial is being conducted within the EBMT-SAAWP using this conditioning regimen.

Description: Acquired marrow failure syndromes may globally affect all hematopoietic lineages, as in aplastic anemia (AA), or may selectively involve single lineages, as in pure red cell (PRCA) or in pure white cell aplasias (PWCA). Because of their common cellular immune-mediated pathophysiology, standard treatment for these conditions includes immunosuppression (IS), which may differ according to the specific disease. We investigated an experimental IS regimen based on the anti-CD52 antibody alemtuzumab (MabCampath®, ALE); the study included a phase II/III prospective trial, as well as a collection of retrospective cases. A total of 32 patients have been treated by ALE (18 SAA, 10 PRCA and 4 PWCA), fourteen of them (mostly PRCA) having not received previous IS. The most utilized schedule (as defined in the prospective trial) was 3,10,30,30,30 mg (total dose 103), administered subcutaneously in consecutive days, with adequate premedication; the last dose was amended in PRCA and PWCA patients (total dose 73 mg). In the prospective trial, all patients also received oral low dose cyclosporine A (1 mg/kg) from day 7, and an intensive anti-infectious prophylaxis, which included oral valgancyclovir and cotrimoxazol. All patients completed the treatment with unrelevant injection-related side effect (fever and/or rash in some cases) and absence of laboratory abnormalities. Complete lympho-ablation was observed in all patients within 2–3 days, which persisted for several weeks; transient worsening of neutropenia and/or thrombocytopenia were observed in some cases. The median follow up was 12 months; there were 5 deaths, only one was possibly related to the treatment. In the prospective trial (n=23), infectious events were rare: a single FUO, associated with fatal complication of an underlying atrial fibrillation, other four viral infections (1 VZV with shingles, 2 HSV and 1 flu), all resolving quickly. No CMV or EBV disease was observed, even if 3 border-line CMV reactivations were documented (after discontinuation of the antiviral prophylaxis), promptly resolved by preemptive valganciclovir. One HBV reactivation without hepatitis required lamivudine. The response rate was globally 61% (42% CR and 19% PR), which raised to 73% (50% CR and 23% PR) when only patients with a follow up of at least 4 months were considered. In the more homogeneous cohort of the prospective trial, response rate was analyzed according to the underlying disease. Among 10 AA treated (5 as first line), 7 had an adequate follow up and showed 4 CR (57%) and 2 PR (29%). Response rate was even higher in 10 PRCA (8 as first line): 7 were evaluable for response, with 5 CR (71%) and 1 PR (14%); the 1 non responding patient subsequently showed evolution to MDS. Finally, 2 of 3 PWCA achieved a CR (66%), with the remaining showing early progression to MDS. Among the responding patients, relapses were quite frequent, even while on cyclosporine: 3/6 SAAs, 5/6 PRCAs and 1/2 PWCA. Relapses were successfully treated by additional ALE (as single shoots or complete courses). Immune reconstitution was delayed up to several months, especially affecting the CD4+ compartment; this was also due to additional ALE needed to treat or to prevent relapses. In conclusion, subcutaneous ALE is a feasible and safe IS regimen for patients suffering from immune-mediated marrow failure syndromes. Preliminary results suggest excellent efficacy, even if responses may be quite late (3–4 months); relapses often occur, but can be easily managed by ALE retreatment. ALE is an excellent alternative to standard IS regimen, and deserves systematic investigation in bone marrow failure patients.

Description: Background: Unrelated cord blood transplantation (UCBT) after reduced intensity conditioning regimen (RIC) has extended the use of UCB in elderly and unfit patients without an HLA identical donor. KIR ligand incompatibility between donor and recipient might favor Natural Killer (NK) cell alloreactivity after UCBT in AML patients (Wilhemze et al, 2009), although contradictory results were reported (Brunstein et al, 2009). We previously reported the results of the biological NK cell reconstitution after RIC-UCBT in a French prospective phase II multicentric trial (Rio et al, 2015). We showed that NK cells generated from RIC-UCBT exhibited features of transient immaturity and stable activation, correlating with a high ability to produce IFN-γ and a quick restoration of the ability both to produce TNF-α and degranulate (Souchet et al, ASH 2013). The aim of the present study is to analyze the impact of KIR ligand incompatibilities and NK cell reconstitution on OS, DFS and TRM after RIC-UCBT in a prospective trial. Materials and methods: Seventy-six patients with a de novo or secondary AML in complete remission were enrolled in 23 centers from Oct. 2007 to Sept. 2009. Peripheral blood samples were collected during the first year following UCBT in order to realize an extensive prospective phenotypic and functional study of NK cells. DNA samples were also collected in recipient and cords blood to perform KIROTYPE and HLA-C allelic typing. NK biological data were available at M1 for 54 patients. The inhibitory Killer-Immunoglobin Receptors (KIR) KIR2DL1, and KIR2DL2/3 bind KIR ligand C2 and C1 respectively, resulting in inhibition of NK-cell mediated lysis. Recipients and UCB were classified into C1 or C2 family depending on their HLA-C typing (C1-C1, C1-C2 or C2-C2). Results: Among the 54 patients, 35 events occurred (relapse or TRM). Median EFS and OS were 13.2 and 18.3 months, respectively. Recipients C2-C2 had a significant worse EFS and OS than C1-C1 or C1-C2 (median EFS C2-C2=3.8 month vs 15.1 month for C1-x; p=0.002); median OS C2-C2 3.8 months vs 29.9 months for C1-x; HR=6.12, IC95% [2.069; 18.113], p=0.001). High intracellular staining of CD107a, reflecting the capacity of NK degranulation with HLA negative K562 target, correlated with better OS. CD107a expression was divided in 2 groups at median (=51%). Median OS of CD107 (0-50%) was 12.8 months vs 20.9 months for CD107a (51-66); p=0.029. Relapse risk was highly increased in recipients C2-C2 (HR=5.04 (IC 95% [1.23; 20.56], p=0.02). Low expression of CD16 (HR=0.97, IC95% [0.937; 0.999], p=0.043), high expression of HLA-DR (HR=1.08, IC95% [1.031; 1.123], p=8e-04) on NK cells, and recipients C2-C2 (HR=9.44, IC95% [1.311; 67.882], p=0.026) significantly increased the risk of TRM. The inhibitory KIR2DL1 receptor binds to C2 ligands. Of interest, KIR2DL1 was significantly decreased on C2-C2 recipients NK cells at M1, as compared to C1-x recipients NK cells. On the contrary, KIR2DL2/3 and KIR3DL1 restored promptly, suggesting a sequential expression of KIRs. As interaction between inhibitory KIRs and their ligands are essential for NK cells to become functional ("licensing" process), we can hypothesize that the weaker expression of KIR2DL1 on C2-C2 NK cells alters the licensing process, rendering the NK cells hypo-responsiveness. Conclusion: Recipient C2-C2 is correlated with a worse outcome (EFS, OS, relapse, TRM) after RIC-UCBT in a prospective trial for AML patients. Weak capacity of degranulation and low expression of CD16 are associated with worse OS and increased TRM, respectively. These features can reflect an alteration of the NK licensing process and might have impact on clinical outcome after UCBT. Disclosures No relevant conflicts of interest to declare.

Description: Abstract 2125 Background: Over the last three decades, progress in the treatment of childhood acute lymphoblastic leukemia (ALL) has considerably improved the outcome of children, leading to 5-year OS of more than 80%. Numerous comparisons, including the French LALA/FRALLE (Boissel et al. JCO 2001), have reported a better outcome in teenagers treated with pediatric as compared to standard historical adult ALL protocols. Even if modern pediatric-inspired adult ALL protocols have recently reported impressive improvements, especially in younger patients (Huguet et al. JCO 2009), the issue of whether younger adults (YAs) should be treated according to pediatric or adult protocols remains an open one. The aim of this study was first to evaluate the feasibility and the results of a non-modified pediatric protocol (the French FRALLE 2000) in adolescents and younger adults (AYAs, aged 15–29 years) treated in adult departments. Methods: From February 2001 to June 2010, 72 AYAs with Ph-negative ALL were treated according to the pediatric FRALLE 2000-BT protocol in 12 adult hematology units in France and Belgium. After a prednisone prephase and a four-drug induction (prednisone, daunorubicin, vincristine and L-asparaginase), patients in CR received a consolidation, a 1st delayed intensification, an interphase, a 2nd delayed intensification, and a maintenance chemotherapy during two years. Results: The median age was 19 years (range, 15–29 years). The cohort was separated in 2 subgroups: 44 adolescents aged 15–19 years and 28 young adults (YAs) aged 20–29 years. There were no significant differences between the adolescent and the YA populations in term of sex ratio, white blood cell count (WBC), central nervous system involvement, and phenotype (BCP- vs T-ALL). As expected, few recurrent cytogenetical abnormalities were identified in this population and did not differed between both subgroups. In the adolescent group, we identified 2 patients with t(4;11), 1 patient with t(1;19), and 3 patients with hypodiploïdy and/or neartriploïdy, whereas this repartition was 2/2/1 in YAs. Rates of good early response to prednisone were in 68% in adolescents and 61% in YAs (p=.52), while rates of good early response to chemotherapy were 80% and 86%, respectively (p=.51). No patient died during induction. Complete remission (CR) rate did not differ between subgroups (98% vs 100%, p=.42). With a median follow up of 4.8 years, 5-year EFS was 57% (41% in adolescents vs 79% in YAs, p=.03) and 5-year OS was 67% (56% and 82% respectively, p=.09). In patients with BCP-ALL, 5-year EFS was 60% (43% in adolescents vs 91% in YAs, p=.02) and 55% in T-ALL (57% vs 50% respectively, p=.81). Twelve patients (17%) received an allogeneic stem cell transplantation (SCT) in first CR (5 adolescents and 7 YAs). Four patients died in first CR, all after SCT, (2 adolescents and 2 YAs). In univariate analysis, a high WBC (continuous variable, p=.02) and a poor early response to chemotherapy (33% vs 63%, p=.02), but not phenotype or poor early response to prednisone, were significantly associated with a shorter EFS. In multivariate analysis, age (adolescents vs YA, p=.04), WBC (continuous variable, p=.0005), and poor early response to chemotherapy (p=.006) had still an impact on EFS. The poor outcome of adolescents compared to YAs, also observed in the French adult GRAALL protocol (not published), was not explained by differences in ALL characteristics, early response to therapy, or treatment-related toxicity. Conclusion: The pediatric protocol FRALLE 2000 is effective and safe for the treatment of selected AYAs with Ph-negative ALL referred to adult departments. The results observed in the YA population are promising, warranting prospective comparisons with the more recent pediatric-inspired adult protocols. The unexpected poorer outcome of adolescents deserves further investigations to explore a potential impact of the quality of care delivered in an adult environment. Disclosures: No relevant conflicts of interest to declare.