ALBERT

Description: The role of transplantation in infants with acute lymphoblastic leukemia (ALL) is not defined. We analyzed results of 40 infants diagnosed before age 12 months who received a hematopoietic cell transplant (HCT) between July 1982 and February 2003 in first complete remission (CR1; n = 17), CR2/3 (n = 7), or relapse (n = 16). Patients were conditioned with cyclophosphamide with total body irradiation (n = 39) or busulfan (n = 1). Donors were matched related (n = 8), mismatched related (n = 16), or unrelated (n = 16). Graft-versus-host disease (GVHD) prophylaxis was methotrexate or cyclosporine (n = 7) or methotrexate plus cyclosporine (n = 33). Thirty-nine patients engrafted, 20 developed acute GVHD, and 7 developed chronic GVHD. Sixteen patients relapsed and 7 died of other causes. Patients in CR1 had disease-free survival (DFS) of 76% compared with 45% for CR2/CR3 and 8% for relapse (P 〈 .001). Of 33 patients with cytogenetic data, 26 (79%) had MLL gene rearrangement. Fourteen of these 26 were in CR1 and 11 survive in remission. Outcome was associated with phase of disease, but having the MLL gene was not a factor predictive of outcome. Late effects included growth and other hormone deficiencies. These data demonstrate that infants with ALL and MLL gene have excellent DFS when they received transplants in CR1, and consideration for transplantation in CR1 is warranted.

Description: Growth impairment and growth hormone (GH) deficiency are complications after total body irradiation (TBI) and hematopoietic cell transplantation (HCT). To determine the impact of GH therapy on growth, the final heights of 90 GH-deficient children who underwent fractionated TBI and HCT for malignancy were evaluated. Changes in height standard deviation (SD) from the diagnosis of GH deficiency to the achievement of final height were compared among 42 who did and 48 who did not receive GH therapy. At HCT, GH-treated patients were younger (P = .001), more likely to have undergone central nervous system irradiation (P = .007), and shorter (P = .005) than patients who did not receive GH therapy. After HCT, GH deficiency was diagnosed at 1.5 years (range, 0.8-9.5 years) for GH-treated and 1.2 years (range, 0.9-8.8 years) for nontreated patients. GH therapy was associated with significantly improved final height in children younger than 10 years at HCT (P = .0001), but GH therapy did not impact the growth of older children. Girls (P = .0001) and children diagnosed with acute myelogenous leukemia (AML), chronic myelogenous leukemia (CML), or myelodysplastic syndromes (MDS) (compared with acute lymphoblastic leukemia [ALL] or non-Hodgkin lymphoma [NHL]; P = .02) also showed more rapid growth than their counterparts. These data demonstrate that GH therapy improves the final height of young children after fractionated TBI.

Description: Thyroid dysfunction is a known complication after hematopoietic cell transplantation (HCT) in children with reports involving relatively short follow-up and small patient numbers. This study involves 791 patients less than 18 years of age at HCT at the Fred Hutchinson Cancer Research Center with follow-up from 1969 through 2007. Thyroid dysfunction continued for 28 years after transplantation. Hypothyroidism was the most common abnormality with other abnormalities of hyperthyroidism and thyroiditis. Multivariate analysis showed that thyroid dysfunction was more likely if patients were less than 10 years of age (P 〈 .001), but there was no difference between receiving a total body irradiation or busulfan based regimens (P = .48) compared with cyclophosphamide conditioning alone (P = .008). Thyroid tumors occurred at a median of 9.9 (4.5-22.3) years after HCT and included 13 with papillary carcinoma and 5 with benign adenomas. Children who receive a HCT should be monitored for thyroid abnormalities throughout life.

Description: Historically, graft-versus-host disease (GVHD) beyond 100 days after hematopoietic cell transplantation (HCT) was called chronic GVHD, even if the clinical manifestations were indistinguishable from acute GVHD. In 2005, the National Institutes of Health (NIH) sponsored a consensus conference that proposed new criteria for diagnosis and classification of chronic GVHD for clinical trials. According to the consensus criteria, clinical manifestations rather than time after transplantation should be used in clinical trials to distinguish chronic GVHD from late acute GVHD, which includes persistent, recurrent, or late-onset acute GVHD. We evaluated major outcomes according to the presence or absence of NIH criteria for chronic GVHD in a retrospective study of 740 patients diagnosed with historically defined chronic GVHD after allogeneic HCT between 1994 and 2000. The presence or absence of NIH criteria for chronic GVHD showed no statistically significant association with survival, risks of nonrelapse mortality or recurrent malignancy, or duration of systemic treatment. Antecedent late acute GVHD was associated with an increased risk of nonrelapse mortality and prolonged treatment among patients with NIH chronic GVHD. Our results support the consensus recommendation that, with appropriate stratification, clinical trials can include patients with late acute GVHD as well as those with NIH chronic GVHD.

Description: This study describes the magnitude of risk of therapy-related myelodysplasia and acute myeloid leukemia (t-MDS/AML) in 578 individuals diagnosed with Ewing sarcoma and enrolled on Children's Oncology Group therapeutic protocol, INT-0091. Between 1988 and 1992, patients with or without metastatic disease were randomized to receive doxorubicin, vincristine, cyclophosphamide, and dactinomycin (regimen A) or these 4 drugs alternating with etoposide and ifosfamide (regimen B). Between 1992 and 1994, patients with metastatic disease were nonrandomly assigned to receive high-intensity therapy (regimen C: regimen B therapy with higher doses of doxorubicin, cyclophosphamide, and ifosfamide). Median age at diagnosis of Ewing sarcoma was 12 years, and median length of follow-up, 8 years. Eleven patients developed t-MDS/AML, resulting in a cumulative incidence of 2% at 5 years. While patients treated on regimens A and B were at a low risk for development of t-MDS/AML (cumulative incidence: 0.4% and 0.9% at 5 years, respectively), patients treated on regimen C were at a 16-fold increased risk of developing t-MDS/AML (cumulative incidence: 11% at 5 years), when compared with those treated on regimen A. Increasing exposure to ifosfamide from 90 to 140 g/m2, cyclophosphamide from 9.6 to 17.6 g/m2, and doxorubicin from 375 to 450 mg/m2 increased the risk of t-MDS/AML significantly.

Description: Abstract 4272 The incidence of Philadelphia positive (Ph+) chronic myeloid leukemia (CML) in Europe is still difficult to estimate, due to insufficient information. Currently, it is believed to range between 8 and 22 cases per million people per year, age adjusted. Prior to the introduction of the tyrosine kinase inhibitor (TKI) imatinib the annual death rate was about 10% for the first 2 to 3 years, and about 20% from the 4th year on, with less than 10% of patients alive after 10 years. Interferon-alfa treatment and allogeneic hematopoietic stem cell transplantation were very effective treatments but only in a minority of patients. Following the introduction of IM, and of the second generation TKI nilotinib and dasatinib the annual death rate has decreased to less than 5%, and more than 75% of patients are projected to be alive 10 years after diagnosis. Based on these figures, the prevalence of the disease is expected to double every 5 years and the management of the disease will rapidly become an important social and pharmacoeconomic issue. To govern this progress it is necessary to improve the level of information on the epidemiology of CML, on the treatment of CML in clinical practice, and on the outcome of treatment outside prospective, controlled clinical trials on which current outcome estimates are based. With that purpose, the European Leukemia Network (ELN) has established a registry of all new cases of Ph+ CML. In a public private partnership with Novartis Oncology Europe this registry has been expanded to also include treatment and quality controlled outcome (European Treatment and Outcome Study [EUTOS] for CML). The infrastructure of the registry is based on a EUTOS Central Scientific Headquarter (Dpt. Hematology-Oncology “L. and A. Seràgnoli”, University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy) and a EUTOS Central Data Center (Dpt. For Medical Informatics, Biometric and Epidemiology, University of Munich, Munich, Germany), interacting with each national hub. Registry is population-based, covers completely most European countries with less than 12 millions inhabitants (Portugal, Belgium, Sweden, Finland, Lithuania, Latvia, Estonia, Czech Republic, Slovakia, Slovenia, Croatia, Serbia, Hungary, Austria, Greece, Cyprus), and covers partially (for larger countries, only sub-regions with roughly 10 millions inhabitants have been selected) most of the countries with more than 12 millions inhabitants, including Spain, the United Kingdom, The Netherlands, Germany, Poland, France, Romania, Russia and Italy. About 2500 newly diagnosed cases are planned to be registered over one year and to be followed for treatment and outcome including cytogenetic response, molecular response, and BCR-ABL KD mutations. Moreover, flanking projects have been implemented in the EUTOS frame: a network of standardized laboratories across Europe, to provide a molecular monitoring with quality controlled data, a central facility for imatinib blood level testing, soon in many European countries, and an educational effort (symposia, training workshops, internet platform). The EUTOS registry joins epidemiological and outcome data: its implementation requires considerable efforts and resources, but in the long run CML could become a model for epidemiologi and management of other cancers. Disclosures: Hasford: Novartis Pharma: Research Funding.

Description: Primary refractory or relapse patients (pts) who have not achieved complete response after salvage or re-induction therapy carry poor prognosis even if additional high-dose chemotherapy is given. In a cohort of 171 pts with relapsed or refractory DLBCL, treated at MSKCC between 1/1/1994 to 9/1/2006 with ICE (ifosfamide, carboplatin, etoposide)-based salvage chemotherapy (44% received ICE+ Rituximab) followed by high dose chemotherapy with autologous stem cell rescue (HDT/ASCR), all pts had post-ICE functional imaging (FI) (Gallium or PET scan). All pts were required to have improvement on CT scan after ICE to be eligible for HDT/ASCR. Involved field radiotherapy (IFRT) was given (prior to HDT/ASCR) to sites of previously unirradiated bulky disease (〉5 cm) or to sites with residual nodal masses of more than 2 cm in size following ICE. IFRT was administered within two weeks in 1.5 Gy fractions twice daily to a total dose of 30 Gy if given alone, or to a dose of 18 Gy if given in combination with 12 Gy fractionated total body irradiation. At a median follow-up of 57 months for surviving pts, there were no treatment-related deaths, and the 5-year progression-free survival (PFS) and overall survival (OS) for the entire cohort was 51% and 57%, respectively. Following ICE-based cytoreduction, FI was positive in 65 pts (38%) and they had an inferior 5 yr PFS (30% vs 61%, p=0.001) and OS (37% vs 67%, p

Description: Protein Z dependent protease inhibitor (ZPI) is a human plasma serpin that inhibits factors Xa and XIa in the coagulation pathway. Kinetic studies have shown that ZPI is an efficient inhibitor of factor Xa. This interaction is accelerated by protein Z in the presence of calcium and phospholipid. The inhibition of factor XIa is by an alternative mechanism that does not require phospholipid but is influenced by both heparin and protein Z; heparin increases inhibition whereas protein Z /calcium delays inhibition. The latter maybe physiologically relevant to XIa inhibitory activity as ZPI and protein Z circulate in complex in plasma, with ZPI in slight excess. The kinetics of ZPI/XIa/heparin interactions have not been fully characterised. In this study we report the kinetic analysis of the interaction between factor XIa and recombinant ZPI expressed in Escherichia coli, in the presence of unfractionated heparin, pentasaccharide and protein Z. Results: Recombinant ZPI (rZPI) had characteristics similar to native protein as previously described; serpin-protease complexes were non-covalent, and reactive centre loop proteolytic cleavage of ZPI was noted during this reaction. On SDS gel rZPI had a molecular weight of 50kDa. Circular dichroism of rZPI showed an unfolding transition on thermal denaturation typical of a serpin in native conformation with a Tm of 58.8°C. In contrast loop cleaved rZPI had increased thermal stability as expected for a serpin. A discontinuous method was used to measure the rate of inhibition of target proteases by rZPI; the first order rate constant was measured over time under pseudo first order conditions, and was used to derive the second order rate constant (ka) as shown in Table 1. Table 1: Second order rate constants (ka) Xa (Ms−1) XIa (Ms−1) * And calcium/phospholipid vesicles ZPI 1.9 x 103 9.0 x 104 ZPI + protein Z* 6.6 x 105 1.8 x 104 ZPI + unfractionated heparin (1IU/mL) - 1.0 x 106 ZPI + pentasaccharide (500nM) - 1.0 x 105 ZPI + protein Z* + unfractionated heparin (1IU/mL) - 6.0 x 105 In the presence of calcium and phospholipid vesicles the ka for Xa in the absence and presence of protein Z was similar to previous reports. The ka for ZPI inhibition of XIa increased 11 fold in the presence of unfractionated heparin. Heparin titration curves suggest that a template mechanism is likely; the heparin pentasaccharide had no impact on inhibition rate consistent with this observation. It has previously been reported that protein Z impedes the ZPI inhibition of XIa; our results support this with a 5-fold reduction in ka. However the addition of heparin to ZPI in the presence of Protein Z leads to a significant 33-fold increase in inhibitory activity with a rate similar to the inhibitory activity of ZPI against Xa in the presence of protein Z. Conclusions: There are several physiological inhibitors of factor XIa. In previous reports ZPI inhibition only increased 2-fold in the presence of heparin. Our results confirm that heparin increases the ZPI inhibition of XIa but with a significantly higher increase than previously reported. The increase in activity is even more marked in the presence of protein Z. Although protein Z alone inhibits ZPI activity against XIa the combination with heparin achieves a 33 fold increase in activity. Of all the serpin inhibitors of XIa, antithrombin is considered a major inhibitor in the presence of heparin. Our results show that the ka for FXIa inhibition in the presence of ZPI, protein Z and heparin is more than 20 fold higher than the ka reported for the antithrombin/heparin inhibition of XIa (2-3x104Ms−1). We have previously reported a higher incidence of venous thrombosis in patients with nonsense mutations in the ZPI gene suggesting the clinical significance of this protein. The suggestion that the inhibition of XIa maybe more relevant than that of Xa has been raised in recent murine work where ZPI knockouts have a more severe phenotype than protein Z knockouts. ZPI inhibition of XIa in the presence of endogenous heparins maybe an important contributor to its physiological significance.

Description: We investigated the role of vascular endothelial (VE)–cadherin in blood vessel morphogenesis and established a temporal correlation linking the failure in vessel morphogenesis in VE-cadherin null embryos to a specific step in vasculogenesis. We showed that the sequence in which blood vessels failed followed the order in which they had formed (ie, those forming first—yolk sac, allantoic and endocardial vessels—were the first to display morphologic abnormalities). We next showed that in place of normal reticulated networks of blood vessels, clusters of platelet endothelial cell adhesion molecule–positive (PECAM+) cells formed within cultured allantois explants from VE-cadherin null embryos. Similarly, a function-blocking VE-cadherin antibody, BV13, caused PECAM+ cell clusters to form in cultured allantois explants from normal mice. Finally, we demonstrated that formation of PECAM+ cell clusters in response to BV13 was not due to a disruption in the formation of nascent vessels but was due to the actual disassembly of nascent vessels. Based on these findings, we conclude that the events of de novo blood vessel formation up to the point at which a vascular epithelium forms (ie, nascent vessels with lumens) are not dependent on VE-cadherin and that VE-cadherin, whose expression is up-regulated following vascular epithelialization, is required to prevent the disassembly of nascent blood vessels.