ALBERT

Description: Background Invasive fungal infections (IFIs) are of great concern after allogeneic hematopoietic stem cell transplantation (HSCT), the risk of which is considered to be particularly prominent among cord blood transplantation (CBT) recipients. Patients and Methods We retrospectively analysed the records of 749 adult patients who underwent CBT or unrelated bone marrow transplantation (uBMT) for the first time at the Toranomon Hospital between 2002 and 2012, and who had neither prior history nor suspicious findings of IFIs. As prophylaxis for IFIs, fluconazole (FLCZ) or itraconazole (ITCZ) capsules were conventionally used until around 2006, which were then changed to newer mold-active agents including ITCZ oral solution, voriconazole or micafungin after their approval in Japan, the choice of which was subjected to physician's discretion. Results Engraftment achieved in 418 CBT patients and 198 uBMT patients with a significantly longer neutropenic period in CBT patients (median 20 days vs 18 days, P

Description: Objectives Fever during neutropenia occurs in 〉 90% and 80% of allogeneic and autologous hematopoietic stem cell transplantation (HSCT) recipients, respectively. Current guidelines recommend the prophylaxis with fluoroquinolones (FQs) in HSCT patients. Although there is evidence that antibiotic prophylaxis improve clinical outcome in patients with chemotherapy-induced neutropenia, prophylactic antibiotic therapy has not been thoroughly evaluated in HSCT recipients. Therefore, we performed a meta-analysis to evaluate the impact of systemic antibiotic prophylaxis in HSCT recipients on mortality, incidence of infection and related adverse events. Data sources We identified reports that were not restricted to those in English and not restricted to published trials through PubMed, the Cochrane Library, and references of identified studies. Review Methods We included prospective, randomized studies on systemic antibiotic prophylaxis in HSCT recipients. The outcome measures included the all-cause mortality, infection-related mortality, febrile episodes, incidence of clinically or microbiologically documented infection, bacteremia, or related adverse events. The summarized odds ratios (ORs) were calculated using the Mantel–Haenszel method and the DerSimonian–Laird method. Results Seventeen trials with 1453 patients (842 autologous and 407 allogeneic HSCT recipients) were included. The percentage of autologous and allogeneic HSCT recipients was not specified in 2 trials. Systemic antibiotic prophylaxis was compared with placebo or no prophylaxis in 10 trials and with non-absorbable antibiotic in 2 trials, respectively. Systemic antibiotics other than FQs were evaluated in five out of these 12 trials. Four trials evaluated the effect of addition of antibiotics for gram positive bacteria to FQs. Remaining 1 trial compared the two different systemic antibiotic regimens, FQs versus trimethoprim sulfamethoxazole. As a result, systemic antibiotic prophylaxis reduced the incidence of febrile episodes (OR 0.16; 95 percent confidence interval [CI], 0.09-0.30), clinically or microbiologically documented infection (OR 0.41; 95% CI 0.30-0.57) and bacteremia (OR 0.37; 95% CI 0.26-0.53) without the significant effect on all-cause mortality or infection-related mortality (OR 0.89; 95% CI 0.48-1.66, OR 1.37; 95% CI 0.50-3.76, respectively). Impact of prophylaxis with FQs on mortality was inconclusive because of small number of clinical trials evaluated. Adverse events increased in patients with systemic antibiotic prophylaxis compared to controls (OR 3.32; 95% CI 1.45-7.63). In meta-regression, percentage of allogeneic HSCT recipients was not associated with each outcome measure. With regard to the comparison between different prophylactic regimens, addition of antibiotics for gram positive bacteria to FQs decreased the incidence of bacteremia (OR 0.44; 0.24-0.80) without significant effects on all-cause mortality, infection related death and febrile episodes. There was not significant, but consistent decrease in clinically or microbiologically documented infection (OR 0.55; 95% CI 0.30-1.01). There was significant increase of adverse events in patients receiving addition of antibiotics for gram positive bacteria to FQs (OR 6.65; 95% CI 2.15-20.54). Conclusions Systemic antibiotic prophylaxis successfully reduced the incidence of infection in HSCT recipients. However, there was no significant impact on mortality. Impact of prophylaxis with FQs on mortality in HSCT recipients was inconclusive because of small number of trials evaluated. Disclosures: No relevant conflicts of interest to declare.

Description: We investigated the pathophysiological significance of MDM2 and the nuclear exporter Exportin 1 (XPO1/CRM1) on p53 transcription and their therapeutic targeting in mantle cell lymphoma (MCL). MCL is currently an incurable B-cell non-Hodgkin's lymphoma. Although TP53 mutations occur rarely (i.e., in 15 to 20% of the cases) in MCL, wild-type p53 is frequently inactivated by gene amplification of BMI1, homozygous deletion of CDKN2A (INK4a/ARF, over-expression of regulatory proteins, or gene deletion. For example, tumor cells may sequester p53 in the cytoplasm via the overexpression of proteins like MDM2 and XPO1 thereby abrogating its transcriptional anti-tumor activity. The selective MDM2 inhibitor Nutlin-3a (Vassilev, 2004) has been reported to induce p53-mediated apoptosis in MCL cells, and recently it was shown that the potent, small molecule Selective Inhibitor of Nuclear Export (SINE) induces apoptosis in MCL cells (Zhang, 2013). mRNA expression levels in MCL patient samples were determined using Oncomine (Compendia Bioscience, Ann Arbor, MI). MDM2 mRNA expression levels were not significantly higher in the MCL samples (n = 8) compared to normal B-cells ( n = 5) (P = 0.27). The MDM2 levels were also not associated with overall disease survival (P = 0.12) at 5 years (n = 63). In contrast, gene expression analysis on the same dataset demonstrated increased XPO1 mRNA expression in the MCL cells versus normal B-cells (P〈 0.001). Furthermore, this higher XPO1 expression was associated with poorer prognosis in MCL patients (i.e., median overall survival: 3.2 years in low expression XPO1 cases and 1.9 years in high expression CRM1 cases, P = 0.033). mRNA levels of 11 representative p53 target genes were determined in 2 MCL (i.e., Z-138 and JVM-2) cells and were compared to those of four acute leukemia (i.e., OCI-AML3, MOLM-13, REH and NALM-6) cells. Cells from all six cell lines express wild-type p53. The MDM2 inhibitor Nutlin-3a (5 µM) poorly induced p53 target genes in the Z-138 (1.9 ± 0.12-fold) and JVM-2 cells (2.1 ± 0.23-fold) compared to acute leukemia cells (13.9 ± 5.2-fold) (P〈 0.001 in both MCL cells), despite their increased p53 protein levels after Nutlin-3a treatment. The data suggest that p53-mediated transcription may be impaired in MCL via a Nutlin-induced increase in cytoplasmic p53 levels. Next, we treated Z-138 with 2 or 4 mM Nutlin-3a or with 80 or 160 nM KPT-185 for 18 hours and determined mRNA changes in p53 targets. KPT-185 induced p53 target genes more potently than Nutlin-3a (i.e., 2- to 4-times). To investigate the significance of p53-mediated apoptosis, Z-138 and JVM-2 were transduced with lentivirus encoding either negative control shRNA (ShC) or p53-specific shRNA (Shp53) and stable shRNA-expressing cells were generated. The p53-specific shRNA reduced p53 basal levels by 80 to 90%, and p53 knockdown cells were ∼80% less sensitive to Nutlin-3a and ∼60% to KPT-185, indicating that MDM2 or XPO1 inhibition rely on p53 pathway to induce apoptosis. Apoptotic induction by Nutlin-3a and KPT-185 in primary MCL cells were determined in 3 samples with wild-type p53. Treatment-specific Annexin V induction percentage in 2.5 µM Nutlin-3a-treated cells was 40.7 ± 8.0%, while it was 64.5 ± 15.0% in 100 nM KPT-185 treated cells. Treatment of 1 µM KPT-185 led to more prominent apoptosis, as evidenced by 81.8 ± 7.7% annexin V staining. Our data suggest that p53 is a component of MDM2 or XPO1 inhibition-induced apoptosis, and p53 transcription is more potently activated by XPO1 inhibition rather than MDM2 inhibition. Based on these data, we propose that active modulation of p53 by SINE XPO1 antagonism and/or MDM2 inhibition transcription would be beneficial in some cancer types to enhance p53-based cancer therapy. Disclosures: Shacham: Karyopharm Therapeutics Inc.: Employment. Kauffman:Karyopharm Therapeutics Inc.: Employment. Andreeff:Karyopharm Therapeutics Inc.: Research Funding.

Description: Background Physician overwork has long been a problem in Japanese society. Mean weekly working durations are reportedly 70.6 hours. The working hours of hematologists are estimated to be especially long. In addition, there is no payment system for specialist medical care in Japan and there is no difference in payments for treatment between specialists and general physicians. The average hourly wage is $30 for both specialists and general physicians in Japan, while the respective values are $100 and $70 in the United States. Given this situation, we advocate that working hours of Japanese hematologists be reduced by improving their work efficiency. One of the problems lies in dose calculations for anticancer drugs. With the conventional ordering system, the method of rounding the dose fractions varies among physicians and there is a potential risk of incorrect administration. We developed an anticancer drug administration system designed to reduce hematologists’ workloads and improve the appropriateness of anticancer drug dosing. We then examined its efficacy. Methods EGMAIN-GX (Fujitsu Ltd., Japan) version 2 is an electronic medical record system incorporating an ordering function. We developed a drug administration system named Regimen version 4 in order to update the EGMAIN-GX version 2 ordering system. The new system allows dose calculation with a rounding function in which the dose is automatically rounded off to the nearest whole number. Seven hematologists were asked to order five regimens (IDR/araC, Flu/ivBU, R-CHOP, hyper-CVAD, R-ESAHP）for a patient (165 cm in height and weighing 52 kg) using the new and old systems. Times required for ordering and prescribed doses of anticancer drugs were compared between the two systems. Statistical analysis was performed using Student’s t test. Results The mean time and standard deviation (seconds) for ordering are shown in Table 1. The time was significantly reduced with version 4 as compared to version 2, except for R-CHOP. The cumulative time was reduced by 54% with version 4. As to the prescribed doses of anticancer drugs, significant differences between the two systems were found in busulfan (42.0 mg vs. 40.7 mg, p 〈 0.0001; figures rounded off to the nearest whole number in the present system, i.e., 42.0 mg) and rituximab (529 mg vs. 583 mg, p= 0.002; figures rounded down to the nearest 100 in the present system, i.e., 500 mg). Conclusions The new drug administration system significantly reduced the time required for ordering and facilitated appropriate anticancer drug dosing. These results show that the new drug administration system can reduce hematologists’ workloads and also reduce the risk of incorrect administration of anticancer drugs. Disclosures: No relevant conflicts of interest to declare.

Description: Purpose It has been proposed that imatinib can be discontinued without molecular relapse at least in some CML patients. But little is known about whether the assumption could be exploitable for the second-generation ABL-tyrosine kinase inhibitors. Here we conducted a prospective, multicenter clinical trial to assess whether dasatinib can be discontinued without occurrence of molecular relapse in CML patients in complete molecular response (CMR). Methods In our Dasatinib Discontinuation (DADI) trial (Japan Primary Registries Network #UMIN000005130, http://rctportal.niph.go.jp/), main eligibility criteria for pre-registration were; CML patients in chronic phase, 15 years and older, undergoing dasatinib treatment used as a second-line therapy after confirmation of resistance or intolerance to imatinib treatment. Previous treatments with interferon-α (IFN-α) or nilotinib were allowed. In this trial, CMR was defined as “No detectable BCR-ABL transcript determined by international scale (IS)-based RQ-PCR at a single central laboratory (BML Inc., Tokyo, Japan, which obtains conversion factor (CF) 0.87).” Patients in CMR status confirmed by RQ-PCR at the central laboratory were pre-registered before the full enrollment for the discontinuation. The pre-registration period was between April 1, 2011, and March 31, 2012. The levels of BCR-ABL transcripts were monitored every 3 months throughout the pre-registration period during the dasatinib treatment. Patients with sustained CMR for one-year duration were then enrolled for the dasatinib-discontinuation stage. In order to detect molecular relapse after the dasatinib-discontinuation, RQ-PCR was performed monthly for the first 12 months, and then every 3 months for the subsequent follow-up. Molecular relapse was defined as positivity of BCR-ABL transcript by RQ-PCR even at one analysis point. Dasatinib was immediately reintroduced in patients who showed molecular relapse during the discontinuation period. After the relapse, RQ-PCR monitoring was performed 1 month, 3 months, 6 months, and 12 months after the reintroduction of dasatinib. Primary endpoint of this study was “Molecular relapse-free survival (MoRFS) rate at 6 months after discontinuation of dasatinib.” Total follow-up duration was set to be 36 months after the discontinuation. In addition to the molecular assessment of the BCR-ABL transcript level, increase of large granular lymphocytes (LGL) in the peripheral blood, in combination with flow cytometry analysis, was also investigated. Results In total, 88 patients were pre-registered at 41 participating institutions in Japan. Among them, a total of 63 patients who maintained stable CMR for one year after pre-registration were enrolled for the dasatinib-discontinuation stage. All of these 63 patients (42 male, 21 female) had been treated with imatinib before the start of the dasatinib treatments. Among these 63, 14 were imatinib-resistant, and 35 were imatinib-intolerant. Other previous treatments were; IFN-α (n=12), nilotinib (n=4), IFN-α and nilotinib (n=1). Median age was 59.5 years (range 24-84). Sokal scores were; low 70%, intermediate 15%, and high 15%. In this interim analysis with a data cut-off date of 31 July 2013, 27 patients out of 88 pre-registered patients were over the observation period of 6 months after the dasatinib-discontinuation. Among 27, 12 patients achieved 6 months-sustained CMR after dasatinib-discontinuation. The estimated MoRFS at 6 months determined by Kaplan-Meier method was 44 % (95%CI 26-62). Reintroduction of dasatinib to the relapsed patients showed rapid molecular responses in all of them. Among the 15 patients who lost CMR after dasatinib-discontinuation, 13 patients were available for the evaluation of reintroduction to CMR. 12 out of 13 patients (92%) returned to CMR again within 3 months (7 patients at 1 month, and 5 patients at 3 months) after the reintroduction, and all these patients have sustained CMR up to now. The remaining one patient out of 13 also showed a marked reduction of the BCR-ABL transcript level at 3 months. Conclusion Dasatinib could be safely discontinued in a proportion of CML patients with stable CMR for at least one year, provided that frequent molecular monitoring is performed. Patients who lost CMR after dasatinib-discontinuation still maintained good sensitivity to the reintroduction of dasatinib. Disclosures: Nakamae: Novartis: Honoraria, Speakers Bureau, Travel/accommodations/meeting expenses, Travel/accommodations/meeting expenses Other; BMS.: Consultancy, Honoraria, Research Funding, Speakers Bureau, Travel/accommodations/meeting expenses Other. Hino:Chugai Pharma: Honoraria, Research Funding, Travel/accommodations/meeting expenses Other. Kimura:Bristol-Myers: Honoraria, Research Funding.

Description: Current first-line treatment options for chronic myeloid leukemia (CML) include imatinib (IM) and the second-generation agents nilotinib and dasatinib. Despite the effectiveness of these tyrosine kinase inhibitors, a small percentage of chronic-phase CML patients are primarily refractory or acquire secondary resistance to these agents. Moreover, the prognosis of patients in blast crisis is still poor despite the use of the current treatment modalities because of drug resistance. The major mechanism of drug resistance is the re-activation of ABL kinase either through mutations in the BCR-ABL gene or by BCR-ABLgene amplification. A novel pan-histone deacetylase inhibitor, panobinostat (formerly LBH589), induces the acetylation of heat shock protein 90, thereby inhibiting its chaperone function in association with its client proteins BCR-ABL, leading to the degradation of BCR-ABL. A new pan–ABL tyrosine kinase inhibitor, ponatinib, is a promising therapeutic option in patients with all kinds of BCR-ABLmutation including T315I. It was thus hypothesized that the combination of panobinostat and ponatinib exerts synergistic cytotoxicity against IM-resistant cells through a mechanism of action different from that of each agent. To test this hypothesis, K562/IM-R1 and Ba/F3/T315I cell lines were evaluated for the cytotoxicity of panobinostat and ponatinib in vitro. K562/IM-R1 cells, established in our previous study, showed BCR-ABL overexpression due to BCR-ABL gene amplification. The Ba/F3/T315I cell line showed BCR-ABL with a T315I mutation. The XTT proliferation assay revealed that K562/IM-R1 cells were 12-fold more IM-resistant (50%-inhibitory concentration (IC50), 7.6 µM) than K562 cells (IC50, 0.6 µM). Ba/F3/T315I cells were refractory to IM treatment (IC50, 34.1 µM) compared with Ba/F3 cells (IC50, 3.4 µM). Panobinostat overcame IM-resistance and inhibited similarly the growth of K562, K562/IM-R1, Ba/F3, and Ba/F3/T315I cells, with IC50 values of around 50 nM (40.0 - 51.0 nM). Ponatinib inhibited the growth of both K562/IM-R1 cells (IC50, 4 nM) and Ba/F3/T315I cells (25 nM) as potently as parental K562 cells (IC50, 2 nM) and Ba/F3 cells (IC50, 5 nM). Importantly, the combination of panobinostat and ponatinib exhibited enhanced growth inhibition effects on all cell lines. The IC50 values for this combination were 0.7 nM for K562 cells, 1.3 nM for K562/IM-R1 cells, 3.7 nM for Ba/F3 cells, and 10 nM for Ba/F3/T315I cells. The combination index clearly showed synergism, with values of 0.5 for K562 cells, 0.28 for K562/IM-R1 cells, 0.9 for Ba/F3 cells, and 0.4 for Ba/F3/T315I cells. When the cells were treated with 10 nM panobinostat or 10 nM ponatinib for 48 h alone or in combination, the combination of the 2 agents led to greater-than-additive apoptotic cell death than each agent alone in all cell lines, evaluated by annexin V-positivity. Western blotting was used to evaluate the protein expression levels of BCR-ABL and phospho-BCR-ABL in cells after treatment with panobinostat or ponatinib or both in combination. BCR-ABL expression was greater in K562/IM-R1 than K562 cells. Phospho-BCR-ABL expression was not inhibited by IM in K562/IM-R1 or Ba/F3/T315I cells. However, ponatinib inhibited the autophosphorylation of BCR-ABL in these cell lines. Treatment with panobinostat reduced the BCR-ABL and phospho-BCR-ABL expression levels in K562/IM-R1 and Ba/F3/T315I cells. The combination of the 2 agents augmented inhibition of the autophosphorylation of BCR-ABL in these IM-resistant cell lines. The activity of histone deacetylase, determined using the HDAC assay Kit (Active Motif, Carlsbad, CA, USA), was inhibited by panobinostat in all cell lines regardless of IM sensitivity. In comparison, IM did not alter cellular histone deacetylase activity. Upon treatment of K562 cells with panobinostat, the protein expression levels of acetylated histone H3 and H4 were increased, suggesting the consequence of the inhibition of histone deacetylase. In conclusion, we firstly reported that panobinostat and ponatinib demonstrated synergistic cytotoxicity against IM-resistant cell lines not only due to BCR-ABL gene amplification but also BCR-ABL T315I mutation. The synergism is attributable to the greater inhibition of ABL kinase activity through a mechanism of action different from that of each agent. Disclosures: No relevant conflicts of interest to declare.

Description: Background ATRA and anthracycline-based chemotherapy is a standard remission induction therapy for APL, leading to complete remission (CR) rate of 90% or more. (Asou et al, 2007; Ades et al, 2010; Avvisati et al, 2011). As reported in many APL studies including the JALSG study, risk adopted strategy according to initial leukocyte counts has demonstrated successful results. However, the long-term outcome of the patients with initial leukocyte counts 〈 3,000/µl received ATRA alone in the induction therapy and followed by post remission chemotherapies, remains to be elucidated. Furthermore, it is controversial whether concomitant chemotherapy is needed for such a very low risk group. In the JALSG-APL97 study, patients with initial leukocyte counts 〈 3,000/µl received ATRA alone until remission (Group AA), except for patients with leukocytosis during the ATRA therapy who received additional chemotherapy (Group AD). Here, we reported the long-term outcome of this study based on risk adopted therapy, particularly, focusing on the outcome of the very low risk group. Methods The treatment schedule of JALSG-APL97 study was initially reported by Asou et al. in 2007. In brief, patient groups were defined as: leukocytes 〈 3000/µl (Group A: ATRA alone), 3000/µl ≤ leukocytes 〈 10,000/µl (Group B: ATRA plus IDA/Ara-C: 2+5), and leukocytes ≥ 10,000/µl (Group C: ATRA plus IDA/Ara-C: 3+5). Patients who experienced leukocytosis received additional chemotherapy (Group D). After 3 courses of consolidation chemotherapy, patients achieved molecular CR were allocated to an intensive chemotherapy group or observation. The CR rate, overall survival (OS), event-free survival (EFS), and cumulative incidence of relapse (CIR) were analyzed for each group. Results Two hundred and seventy-one newly diagnosed APL patients, ranging from 15 to 70 years of age, were evaluable. The number of patients in each group was 150 (A), 69 (B), 52 (C) and 70 (D), respectively. Of 150 patients in Group A, 83 achieved CR with ATRA alone (AA), and 67 were added chemotherapy due to leukocytosis during ATRA therapy (AD). In Group A, B, C and D, CR rates were 95.2%, 97.0%, 90.4% and 97.1%, respectively (P = 0.30); OS (Figure 1) 90.1%, 77.3%, 73.1% and 71.4%, respectively (P = 0.02); EFS (Figure 2) 71.1%, 63.6%, 55.7% and 64.3%, respectively (P = 0.26); CIR 23.5%, 27.6%, 34.5% and 20.4% (P = 0.51), respectively. Initial leukocyte counts in Group AA were significantly lower compared to those in Group AD (median leukocyte counts; 900/µl vs. 1,100/µl, P = 0.03). The median administration period of ATRA was similar between Group AA and AD (46 days vs. 43 days, P = 0.57). Differentiation syndrome was more frequent in Group AA (28.0% vs. 14.9%, P = 0.04). The CR rate and early death rate were not different between two groups (95.2% vs. 95.5%, P = 0.92 and 3.6% vs. 4.5%, P = 0.79, respectively). OS was significantly inferior (90.1% vs. 73.1%, P = 0.005) and non-relapse mortality after post-remission therapy was significantly higher in Group AD (5% vs. 16%, P = 0.04), compared to Group AA, while EFS was not different between two groups (71.1% vs. 65.7%, P = 0.33). The cumulative incidence of late relapse occurred more than 2 years after CR was significantly higher in Group AA compared to Group AD (17.5% vs. 3.9%, P = 0.04). Conclusions Risk adopted therapy according to initial leukocyte counts is totally useful in this study as well as previous reports including us. OS was favorable in APL patients with initial leukocyte counts 〈 3,000/µl, achieved CR by using ATRA alone for remission induction therapy, whereas EFS in this group was still unsatisfactory in the long-term follow up. It could be explained by the high frequency of late relapse. Ades et al reported better long-term outcomes in patients concomitantly treated with ATRA and chemotherapy rather than in those treated with ATRA followed by chemotherapy in their APL patients with initial leukocyte counts 〈 5000/µL. However, very low risk patients (Group AA) could be put into the separate category, and therapeutic approaches to reduce the late relapse in this group should be discussed. Additionally, the genetic profile studies will provide us informative data in relation to initial leukocyte counts and leukocytosis during ATRA therapy. Disclosures: Kiyoi: Bristol-Myers Squibb: Research Funding; Chugai Pharmaceutical Co., Ltd.: Research Funding; Novartis Pharma: Research Funding; Kyowa Hakko Kirin Co. Ltd.: Research Funding.

Description: Background Recent studies have investigated the pathogenesis of the class of conditions known as “other iatrogenic immunodeficiency-associated lymphoproliferative diseases” (OIIA-LPDs), particularly in patients with rheumatoid arthritis (RA). Methotrexate (MTX) is a potent cause of LPDs, and withdrawal of MTX can result in spontaneous regression of LPD, which suggests that this drug plays an important role in the tumorigenesis of LPDs. In addition, an impaired immunity against Epstein-Barr virus (EBV) has been obserbed in RA patients. A number of reports describe LPD regression in patients with OIIA-LPDs-RA, but its precise etiology and pathogenesis remain unclear. Furthermore, the phenomenon of relapse/regrowth of LPDs after initial regression has not been well documented. This study retrospectively analyzed the clinicopathological features of OIIA-LPDs-RA patients to determine the influence of EBV infection on regression/relapse of the disease. Methods & Results Data were collected from 35 patients with RA who developed LPD and who were treated at our institute between 1998 and 2013. All patients had received treatment with MTX. The diagnosis of RA was made according to the American College of Rheumatology criteria. Based on immunohistochemistry performed on paraffin-embedded tissue sections, diagnoses were as follows: diffuse large B cell lymphoma (DLBCL; n=14), Hodgkin lymphoma (HL; n=7), follicular lymphoma (FL; n=4), mucosal-associated lymphoid tissue (MALT; n=3), Hodgkin-like lymphoma (HL-like; n=3), T-cell lymphoma (n=3), polymorphic LPD (P-LPD; n=2) according to the 4th WHO classification. Regarding EBV infection, 16 patients (44%) were positive. Patients with FL, MALT, and T-cell lymphoma were negative for EBV, except for one patient with T-cell lymphoma. In contrast, EBV infection positivity was prevalent in patients with DLBCL, HL, HL-like and P-LPD (46%, 100%, 100%, and 50%, respectively). Although HL indicated a specific phenotype, such as positivity for CD15 and CD30 (83%, and 100%, respectively), and rarely expressed CD20, OCT2 or BOB1 (0%, 14%, 14%, respectively), the phenotypes of HL-like and P-LPD were supposedly intermediate between DLBCL and HL. The phenotypes of FL, MALT, and T-cell lymphoma were the same as those of de novo cases. LPD regression was observed in 23 (66%) of 35 patients, which is more common than that seen in previous reports. Although LPD regression was not documented in patients with T-cell lymphoma, it did occur in all patients with HL, HL-like and P-LPD. In addition, the incidence of regression among patients with DLBCL, FL and MALT was 46%, 75% and 33%, respectively. The relationship between EBV infection and LPD regression among patients with HL, DLBCL, HL-like and P-LPD was statistically significant (p=0.048, Fisher's exact test). Of 23 patients with regression, 13 patients (56%) subsequently showed relapse/regrowth, and the incidence of this phenomenon was relatively high in patients with HL, HL-like and P-LPD (100%, 67%, and 50%, respectively), whereas a lower incidence was seen in patients with DLBCL, FL, and MALT (7%, 33%, and 0%, respectively). Summary/Conclusions LPD regression was relatively common (66%) in patients with OIIA-LPDs-RA, particularly in patients with B cell phenotypes. There was a significant relationship between LPDs and EBV infection in patients with HL, DLBCL and HL-like, suggesting that underlying EBV infection might influence the immunosuppressant effect of MTX against EBV in those phenotypes. Further, LPD relapse/regrowth was common in patients with HL, HL-like and P-LPD and was unlikely in patients with DLBCL. Further studies would be of benefit to investigate the underlying molecular mechanism of regression/relapse of LPD after withdrawal of MTX. Disclosures: No relevant conflicts of interest to declare.

Description: Background Nilotinib has shown superiority over imatinib for treating pts with newly diagnosed CML-CP. Additionally, pts who are resistant or intolerant to imatinib can often achieve improved responses by switching to nilotinib. However, the value of switching pts to nilotinib due to molecular SoR on imatinib is not well characterized. The Study to Evaluate Nilotinib in CML pts with SubOptimal Response (SENSOR) was therefore conducted to evaluate the efficacy and safety of nilotinib 400 mg BID in pts with CML-CP with SoR to frontline imatinib. Here, we present results of a planned 12-mo interim analysis. Methods SENSOR (NCT01043874) is an open-label, multicenter, phase IV study. Adult pts with CML-CP in complete cytogenetic response but not in major molecular response (MMR; defined as BCR-ABL ≤ 0.1% on the International Scale [IS]) after ≥ 18 mo on frontline imatinib (SoR as defined by 2009 European LeukemiaNet criteria) were eligible to enroll and switch to nilotinib 400 mg BID. Molecular responses were assessed prior to enrollment, at 1, 2, and 3 mo and every 3 mo thereafter. Mutational analyses were performed at baseline (BL) and at end of study in all pts, every 3 mo in pts with BL mutations, and with any ≥ 5-fold increase in BCR-ABL from the lowest level in pts not in MMR. All of these assays were done at a single central laboratory. The primary endpoint was the rate of MMR at 12 mo. Planned enrollment was 45 pts in order to provide a ≥ 25% lower limit of the 95% CI with an expected MMR rate of 40%. Planned follow-up was 24 mo. Results Planned enrollment of 45 pts was completed between Dec 2009 and Feb 2012. Median age of pts was 47 years (range, 19-80). Pts had received imatinib for a median of 23.0 mo (range, 17.0-103.3) at a median daily dose of 400 mg (range, 297-628). Median BL BCR-ABL/ABL ratio was 0.24% (range, 0.11-3.49). At the cutoff date, 19 pts (42%) had completed the study (24 mo follow-up), and 21 (47%) had nilotinib treatment ongoing. Median nilotinib duration was 19.1 mo (range, 0.1-22.7) and median dose intensity was 733 mg/day (range, 183-800). Five (11%) pts discontinued from study treatment for the following reasons: adverse events (AEs; n = 2), disease progression (n = 1), withdrawal of consent (n = 1), and administrative problems (n = 1). At 12 mo, the MMR rate was 51.1% and the median BCR-ABL/ABL ratio was 0.10% (range, ≤ 0.0032-1.62). The cumulative rate of MMR by 12 mo was 66.7%. Among 34 pts with MMR at any time, median time to first MMR was 2.28 mo. No pt who achieved MMR had confirmed loss of MMR (BCR-ABLIS 〉 0.1% with a ≥ 5-fold increase in BCR-ABL transcripts from the lowest level achieved on study in 2 consecutive samples) by the cutoff date (Table). Two pts (4.4%) achieved BCR-ABLIS ≤ 0.0032% at 12 mo. BCR-ABL mutations were detected at BL in 5 pts (E255K, E459K + exon 8/9 35 base pair insertion, Q252R, M244V, and exon 7 deletion), all of whom achieved MMR on nilotinib. Mutations were identified during treatment in 13 pts, 2 of whom had the same mutation at BL; 10 of these pts achieved MMR. One pt developed a T315I mutation, progressed at 5.4 mo, and died at 9.4 mo. These were the only reported events for progression-free survival and overall survival (1 each). The safety profile of nilotinib was consistent with previous studies. Drug-related AEs (any grade) occurring in ≥ 20% of pts included hyperbilirubinemia (53.3%), increased ALT (28.9%), headache (28.9%), hypophosphatemia (26.7%), rash (26.7%), and increased lipase (24.4%). Grade 3/4 newly occurring/worsening abnormal hematology values were hemoglobin (6.7%), neutrophils (4.4%), platelet count (2.2%), and decreased total white blood cells (2.2%). Six pts had serious AEs (2 with suspected relation to study drug [anemia and erythema multiforme]). Conclusions After switching to nilotinib, MMR was rapidly achieved in the majority of pts. These results support the clinical benefit of switching to nilotinib in pts with molecular SoR to imatinib. Disclosures: Miyamura: Novartis: Speakers Bureau; JRC Nagoya 1st Hospital: Employment. Miyamoto:Kyushu University Hospital: Employment. Kurokawa:Celgene: Consultancy, Research Funding; Bristol Myers Squibb: Research Funding; Novartis: Consultancy, Research Funding. Yamamoto:Novartis: Honoraria, Research Funding. Taniwaki:Novartis: Honoraria. Kimura:Novartis: Honoraria, Research Funding; BMS: Honoraria, Research Funding. Ohyashiki:Novartis: Honoraria, Research Funding. Kawaguchi:Novartis: Honoraria. Matsumura:Bristol Myers Squibb: Honoraria; Novartis: Consultancy, Honoraria, Research Funding. Tsurumi:Novartis: Honoraria. Hino:Novartis: Research Funding. Tadokoro:Novartis: Guest speaker in a scientific meeting sponsored by Novartis Other. Hyodo:Hiroshima University: Employment. Kubo:Aomori Prefectural Central Hospital: Employment; Novartis: Honoraria. Kondo:Novartis: Employment. Amagasaki:Novartis: Employment. Kawahara:Novartis: Employment. Yanada:Novartis: Consultancy.

Description: Myeloproliferative Neoplasms (MPNs) are characterized by clonal proliferative hematopoiesis with increased mature blood cells. The signal-activating mutations such as JAK2V617F increase blood cells, but it remains uncertain how an abnormal hematopoietic cell clone expands in MPNs. We have recently showed that overexpression of the high mobility group AT-hook 2 (HMGA2) causes proliferative hematopoiesis with providing a clonal growth advantage to hematopoietic cells in mice (Ikeda et al, Blood, 2011), suggesting the possibility that HMGA2 contributes to the pathogenesis of MPNs. However, since only a few studies have evaluated expression of HMGA2 mRNA in patients with MPNs, the role of HMGA2 in the pathogenesis of MPNs is yet unclear. MPNs also show mutations in epigenetic modifiers involving DNA methylation such as polycomb group genes (PcG) and aberrant expressions of micro RNAs (miRNA) that negatively regulate expressions of targeted genes. Interestingly, deficiency in either PcG-related BMI1 (Oguro et al, J Exp Med, 2012) or let-7-family miRNA (Mayr et al, Science, 2007) causes deregulation of HMGA2 expression, leading to its oncogenic activity in part by negatively regulating tumor suppressor p16. Thus, in this study, to clarify the role of HMGA2 in MPNs, we investigated expression of HMGA2 mRNA in peripheral granulocytes of 56 patients with MPNs including 23 polycythemia vera (PV), 26 essential thrombocythemia (ET) and 7 primary myelofibrosis (PMF) along with clinical findings, JAK2V617F allele burden, expressions of BMI1 mRNA and let-7-family miRNAs, and promoter methylation of p16. Quantitative RT-PCR (qPCR) showed significantly higher expression of HMGA2 mRNA relative to internal control HPRT1 mRNA in PMF (mean ± SD; 31.7 ± 42.8, p1.2), which was determined as relative expression level above mean + 2SD of HMGA2 mRNA in 12 HV, was most frequently detected in patients with PMF [7/7 (100%)] (p