ALBERT

Description: Allogeneic Hematopoietic Cell Transplants in Patients with Myelofibrosis ≥ 60 years of age. Primary myelofibrosis (PMF) and myelofibrosis arising from polycythemia vera (PV) and essential thrombocythemia (ET) are challenging clinical entities and many patients have a very poor prognosis. For the most part, treatment is palliative and often of limited efficacy. Allogeneic hematopoietic cell transplants (HCT) can effectively control the disease, and reduced intensity conditioning regimens have reduced regimen related complications. However, many studies have excluded patients older than age 65 (or even 60) years. This is problematic as the median age at diagnosis is approximately 67. We retrospectively evaluated a cohort of 26 patients age ≥ 60 years with PMF or post PV or ET myelofibrosis who underwent allogeneic HCT between 1999 and 2007. The median age was 63 (range 60–75) years; 9 of these patients were older than 65 (range 66–75) years. Donors were HLA-matched siblings (n=14) or unrelated (n=12). Conditioning regimens included Fludarabine (Flu)/2 Gy TBI (n=16), Flu/Campath(Cam)/TBI (n=2), Flu/Melphalan/ATG (n=2), Cam/Flu/CD45Mab/4.5 Gy TBI (n=2), Flu/Busulfan (Bu) (n=2), Flu/Bu/ATG (n=1), Flu/Mel/Cam (n=1). The median follow up for the cohort was 200 (range 17 – 1322) days. Eleven of 26 patients were alive at the date of last followup, and 9 were relapse free. The median follow up for living patients was 251 (range 100 – 1322) days. Of the 15 patients who had died, 5 died of disease progression and the remaining 10 of non-relapse causes: infection (n=4), GVHD (n=2), respiratory failure (n=2), multi-organ failure (n=1), dissecting aneurysm (n=1). At last follow up, 4 of 9 patients age 〉65 were alive a median of 374 (range 132 – 896) days without disease relapse. Five of the nine patients died, 4 from non-relapse causes and one with disease progression. In summary, reduced intensity conditioning and allogeneic transplantation in patients with myelofibrosis more than 60 years of age resulted in relapse-free survival of 40–45%. While the mortality rate was high, the success rate was remarkable in view of the patient age and the frequent presence of co-morbid conditions. We suggest, therefore, that ongoing and future clinical trials of allogeneic HCT for myelofibrosis should allow enrollment of older patients.

Description: Cytogenetics are an important prognostic factor for patients with myelodysplastic syndromes (MDS). However, the most commonly employed cytogenetics grouping scheme, as used in the IPSS, was derived from a cohort of patients who primarily received supportive care. This scheme may therefore not be optimal for stratifying patients undergoing aggressive therapy such as allogeneic stem cell transplantation (SCT). We previously proposed an SCT-specific cytogenetics grouping scheme for patients with MDS and AML arising from MDS (mAML), based on single-institution data. That scheme allowed for better prognostic stratification than the IPSS scheme. We undertook the present retrospective multicenter study to validate those results. Included were 546 patients with MDS or mAML from the Fred Hutchinson Cancer Center, the M.D. Anderson Cancer Center, and Princess Margaret Hospital. The median age was 53 years (range 18–74). 27% of patients had high-risk MDS (RAEB 1 or 2), and 43% had mAML; 17% had therapy-related disease. Overall 61% of patients were untreated at the time of SCT, while 12% were in CR following treatment. 68% received a conventional intensity conditioning regimen, and 65% were transplanted with peripheral blood stem cells. Donors were matched related (46%), matched unrelated (36%), or mismatched (18%). Cytogenetics were available for 86% of patients. Of those, 47% had favorable, 25% intermediate, and 28% adverse cytogenetics, when grouped by IPSS category. With a median follow-up of 48 months, 4-year relapse-free and overall survivals were 36% and 40%, respectively. In multivariate analyses, variables significantly associated with overall survival were cytogenetics, disease type and stage, patient age, donor match, and year of transplantation. Notably, therapy-related disease was not associated with increased mortality in this model. The optimal cytogenetics grouping scheme comprised two groups, with abnormalities of chromosome 7 and complex karyotype being adverse, and all other abnormalities (including normal karyotype, del(5q), and del(20q)) being standard risk. Adverse cytogenetics was the strongest prognostic factor for SCT outcome in this cohort, with a hazard ratio for mortality of 2.1 (p

Description: We showed previously that the presence of aberrant marrow myeloblasts, as determined by flow cytometry immediately pre-transplant had predictive value for post-transplant outcomes in patients undergoing hematopoietic cell transplantation (HCT) for Myelodysplastic Syndrome (MDS). The characteristics of phenotypically abnormal myeloblasts in MDS include decreased expression of CD45, presence of non-lineage lymphoid antigens including CD56, and differences in the intensity of various myeloid antigens in comparison to healthy controls. In the present study, the bone marrow aspirates of 156 patients with MDS were analyzed before HCT for the presence of abnormal myeloblasts with the aim of determining whether myeloid dyspoiesis by flow cytometry was predictive of post-transplant outcomes, specifically in patients who were considered good risk by currently accepted criteria. All patients received ”myeloablative” conditioning, which in most patients (78%) consisted of busulfan (targeted) and cyclophosphamide followed by HLA-identical related (52%), HLA-matched unrelated (39%), or alternative donor (9%) stem cell infusions. In agreement with our initial report, patients with severe flow scores (≥4) had an increased hazard of relapse (HR=2.7, 95% CI_1.1–6.3, p=0.017) in comparison to patients with normal flow scores. In addition, even among patients with less than 5% marrow myeloblasts, dyspoietic characteristics of the blasts, as assessed by flow cytometry criteria were associated with an increased hazard of relapse (HR=4.0, 95% CI 1.4–12.1, p=0.013) as compared to patients without dyspoiesis by flow. The cumulative incidence of relapse in MDS patients with flow cytometrically normal marrow myeloblasts was 11.7%, compared to 28.1% in patients with less than 5% but phenotypically aberrant myeloblasts; the latter was not different from a relapse incidence of 31.4% in patients with 5% or more abnormal marrow myeloblasts. Furthermore, patients with intermediate-1 risk disease by the International Prognostic Scoring System, who showed flow cytometric aberrancies were at significantly increased risk of relapse (HR=4.2, p=0.01) in comparison to patients with intermediate-1 risk disease and no or mild dyspoiesis by flow cytometry. Thus, the presence of dyspoietic changes was more relevant than the proportion of marrow myeloblasts in predicting the risk of relapse, suggesting that flow cytometry is a powerful tool to select high risk patients from cohorts of patients who by established criteria would be considered to have good risk MDS.

Description: Abstract 2227 Poster Board II-204 Acute graft-versus-host disease (GVHD) contributes to morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT) and more effective prevention and treatment strategies are needed. The 3-hydroxy-3-methylglutaryl coenzyme A-reductase inhibitors (statins) have been shown to possess immunomodulatory properties in vitro and in vivo. To determine whether donor or recipient statin use may affect the risk of GVHD, we retrospectively analyzed outcomes among 567 patients with hematologic malignancies who had hematopoietic cell transplantation from HLA-matched related donors at a single institution between 2001 and 2007. Compared to allografts where neither the donor nor recipient was treated with a statin at the time of transplant (n=464), statin use by the donor and not the recipient (n=75) was associated with a profoundly decreased risk of grade 3-4 acute GVHD (multivariate hazard ratio [HR], 0.28; 95= confidence interval [CI], 0.1-0.9; p=0.03) (Table). Statin use by both donor and recipient (n=12) was suggestively associated with a decreased risk of grade 3-4 acute GVHD (HR, 0.00; 95= CI, undefined; p=0.06), while statin use by the recipient and not the donor (n=16) did not confer GVHD-protection. Risks of chronic GVHD, recurrent malignancy, non-relapse mortality and overall mortality were not significantly affected by donor or recipient statin exposure. Statin-associated GVHD-protection was restricted to recipients with cyclosporine-based postgrafting immunosuppression (n=417; 74=) and was not observed among those given tacrolimus (significance of effect modification: cyclosporine vs. tacrolimus, p=0.009). These results suggest that donor statin treatment may be a promising strategy for preventing severe acute GVHD without compromising immunologic control of the underlying malignancy. Disclosures: No relevant conflicts of interest to declare.

Description: Background: MDSs are clonal hematopoietic stem cell malignancies characterized by cytopenias resulting from ineffective hematopoiesis. A phase 2 study of lenalidomide (MDS-002) demonstrated hematological improvement in patients with MDS without an associated deletion 5q cytogenetic abnormality (List AF, et al. Haematologica2006;91[suppl1]:379[abst 1032]). We now report multicenter results after 〉2 yrs follow-up. Methods: A total of 214 pts with transfusion-dependent anemia were categorized into the following IPSS MDS risk groups after central review of bone marrow morphology, karyotype, and peripheral blood findings: Low/Int-1 (168 [78%]); Int-2/High (8 [4%]); and unclassified (38 [18%]). Patients were unclassified for missing or inadequate marrow studies for central review (morphology [29] or cytogenetic [7]) or other diagnoses (AML [1], atypical CML [1]). Patients were evaluated for frequency and duration of red blood cell transfusion independence (RBC-TI) (IWG criteria), hemoglobin (Hgb) response, and safety. The starting dose of lenalidomide was 10 mg (daily or daily × 3 wks q28d cycle). Results: Overall, 56 (26%) of 214 enrolled patients achieved RBC-TI. Median time to RBC-TI was 5 wks, median duration of RBC-TI response was 41.0 wks (range, 8.0–136.4), and median Hgb increase achieved during RBC-TI was 3.2 g/dL (range, 1.0–9.8). An additional 36 patients experienced a ≥ 50% reduction in RBC transfusions (overall hematological improvement in 92 [43%] patients). Overall, 47 (22%) patients had an abnormal karyotype at baseline and 9 (19%) patients achieved a cytogenetic response (4 complete). The most common drug-related grade 3/4 adverse events (AEs) were neutropenia and thrombocytopenia (25% and 20%, respectively). Deep vein thrombosis occurred in only 2 (1%) patients. The duration of RBC-TI was ≥ 52 weeks in 21 (38%) patients. Among these 21 patients, 14 (67%) did not require a lenalidomide dose reduction during the first 52 weeks of treatment. Analyses of response variables will be presented. Dose-limiting neutropenia/thrombocytopenia was not reported after 52 weeks. The most commonly reported AEs after 52 weeks were mild-moderate diarrhea and fatigue (38% and 29%, respectively). Conclusion: Lenalidomide is an active, well-tolerated treatment in MDS patients with transfusion-dependent anemia that is not associated with a deletion 5q abnormality. The rate of erythroid hematologic improvement and duration of RBC-TI is encouraging and offers a possible alternative to cytokine therapy.

Description: Transferrin (Tf) plays a central role in iron transport and metabolism. In addition, we showed that Tf interferes with programmed cell death. Specifically, Tf counteracted Fas-induced liver injury by down-regulating pro-apoptotic and up-regulating anti-apoptotic signals; those signals were further modified by iron. Surprisingly, the data suggested, that the Tf effect was not mediated by Tf-receptor type 1 (TfR1, CD71). Here, we investigated in murine models a possible role of TfR type 2 (TfR2) in Tf-mediated hepatoprotection. TfR2 is prominently expressed on hepatocytes. Male and female C57BL6, BALB/c, SVJ/129 mice, and mice with deletion of TfR2 (TfR2Y245X) were used. Mice were injected intraperitoneally with agonistic anti-Fas MAB (aFas) Jo2, 0.08 mg/g of body weight and treated with saline (controls) or human ApoTf at 0.1 mg/mouse at 48, 24, and 1 hour before, and 1 hour after aFas injection. Plasma iron and aspartate-aminotransferase (AST) levels were determined at 0, 6, 12, 24, 48 hours and 7 days after aFas. The magnitude of AST rises differed significantly between strains and were less striking in male than in female mice in response to the same per body weight doses of aFas. C57BL6 mice showed the smallest AST increments as compared to BALB/c or SVJ/129 mice. The highest AST levels occurred in female SVJ/129 mice (8934±1833 U/L) versus 3912±1280 U/L in female BALB/c, and 660±159 U/L in female C57BL6 mice. The corresponding baseline plasma iron levels (male and female) were 240–290, 220–270, and 140–170 ug/dL, respectively. Changes in iron levels were biphasic and most pronounced in female mice. In C57BL6, for example, iron decreased from 148±13 ug/dL to 73±8 ug/dL (p

Description: We developed a new HCT-specific comorbidity index (HCT-CI) as a sensitive tool to capture pretransplant comorbidties among pts given allogeneic HCT (Sorror et al, online, 2005; DOI 10.1182/blood-2005-05-2004). In the current report, we used the HCT-CI to explore differences in the tolerability of nonablative compared to ablative HCT in MDS or AML pts with pretransplant comorbidities. Consecutive pts (n=88) receiving nonablative conditioning with 2 Gy total body irradiation (TBI) alone (6%) or with 90 mg/kg of fludarabine (94%) were compared to concurrent pts (n=361) conditioned with cyclophosphamide plus busulfan (70%) or 12–14 Gy TBI (30%). All pts were classified into low (AML-first complete remission or MDS-refractory anemia) and high-risk disease (all others). Overall, 76% of nonablative pts had AML compared to 66% of ablative pts. At HCT, nonablative pts differed substantially from ablative pts with respect to age (median 60 vs 46 years), use of unrelated donor grafts (57% vs 42%), use of marrow grafts (5% vs 20%), and HCT-CI scores of ≥2 (75% vs 45%). Smaller differences existed for high-risk disease (64% vs 58%) and pt cytomegalovirus positive sero-status (59% vs 55%). Proportional hazards models were used to estimate the hazard ratio (HR) for non-relapse mortality (NRM) and survival for pts receiving nonablative compared to ablative conditioning regimens; these models were adjusted for stem cell source, pt age, donor type, pt cytomegalovirus sero-status, diagnoses (MDS vs AML), and HCT-CI scores (Table). Adjusted HRs were not statistically significantly different, except among pts with high-risk disease and HCT-CI scores of ≥2 where nonablative pts had lower HR for NRM (0.34, P=0.005) and worse survival (0.51, P=0.006, Fig.1). These results suggest that pts with high-risk MDS or AML and HCT-CI scores of ≥2 might have less NRM and better survival with nonablative than with ablative HCT. Prospective randomized trials are warranted to confirm this retrospective observation. Additional data are needed for AML and MDS pts with low comorbidities or low disease risk in order to clarify the usefulness of nonmyeloablative conditioning. Table: Adjusted hazard ratios for pts receiving nonablative relative to ablative conditioning Nonablative/ablative NRM Survival Number HR* (95% CI) P HR* (95% CI) P *HR

Description: The poor survival of elderly patients with advanced AML or high-risk MDS following conventional chemotherapy, as well as their poor tolerance for high-dose regimens used in conventional myeloablative hematopoietic cell transplantation (HCT) demands innovative therapeutic approaches. Recent success achieving stable donor chimerism following infusion of allogeneic peripheral blood stem cells (PBSC) after reduced intensity (non-myeloablative) conditioning regimens affords an opportunity to safely induce a graft-vs-leukemia (GVL) effect with minimal acute morbidity. GVL effects, however, appear to be most potent in patients with low tumor burdens at the time of transplantation. We have therefore conducted a Phase I clinical trial of targeted hematopoietic irradiation delivered by an 131I-labeled anti-CD45 antibody (BC8) to determine the feasibility, safety and efficacy of this approach toward reducing the burden of disease before an established non-myeloablative regimen. In this dose escalation study designed to estimate the maximum tolerated dose of 131I-BC8 antibody that can be combined with fludarabine (FLU) and low dose total body irradiation (TBI), 33 patients over 50 years of age with advanced AML or high-risk MDS (〉 5% blasts) were treated with 246 to 932 mCi 131I delivering an estimated 5.2 to 45.9 (mean 27.5) Gy to bone marrow, 17.3 to 155 (mean 81.2) Gy to spleen, and 12–24 Gy to the liver (dose-limiting organ). Patients then received FLU (30 mg/m2 daily for 3 days), 2 Gy TBI, and HLA-matched related (n = 10) or unrelated (n = 23) PBSC grafts with graft-vs-host disease prophylaxis provided by cyclosporine and mycophenolate mofetil. The median age of patients was 61 (50–71) years. Twenty-four patients had AML, with 6 (13%) patients in second or third complete remission, 2 (4%) with primary refractory disease, and 16 (35%) in relapse. Nine (20%) patients had MDS with 〉5% blasts. Treatment with the 131I-BC8 Ab/FLU/TBI regimen produced a remission in all patients, and all had 100% donor CD3+ and CD33+ cell engraftment by day 28 post-transplant. The absolute neutrophil count surpassed 500/uL at a median of 14 (range, 10–19) days, and the self-sustained platelet count surpassed 20,000/uL at a median of 17 days (range, 15–43). Eighteen patients (55%) are surviving disease-free 2 to 16 months (median 9.5 months) post-transplant. In 9 (27%) patients, the disease relapsed 3 to 38 months after HCT. The day-100 non-relapse mortality was 12%. This study demonstrates that at least an average of 27 Gy of targeted radiotherapy can be delivered to bone marrow and an average of 81 Gy to the spleen, in addition to a standard reduced intensity transplant regimen, without a marked increase in day 100 mortality. Whether this approach will reduce post-transplant relapse rates for older patients with high-risk AML/MDS remains to be determined.

Description: A total of 152 patients with myelodysplastic syndrome (MDS) receiving a first stem cell transplant had marrow cells prospectively analyzed to calculate the flow cytometric scoring system (FCSS) score. The FCSS scores were retrospectively compared with patient outcomes in both univariate and multivariate models. The cumulative incidence of posttransplantation relapse at 3 years was 15%, 10%, and 36% for patients with mild, moderate, and severe FCSS scores, respectively, with the hazard for relapse of 2.8 (P = .02) for severe scores in comparison to patients with mild or normal FCSS scores. In multivariate analyses, the FCSS score was associated with relapse even after accounting for International Prognostic Scoring System (IPSS) score or for marrow myeloblast percentage. Among patients with intermediate-1 risk by IPSS, severe FCSS scores were associated with an increased hazard of relapse (3.8; P = .02) compared with patients with normal/mild/moderate FCSS scores. Among patients with less than 5% marrow myeloblasts, myeloblast dyspoiesis was associated with an increased hazard of relapse (3.7; P = .02). This analysis confirmed that FCSS scores are predictive of posttransplantation outcomes in patients with MDS even after adjusting for risk factors such as marrow myeloblast percentage and IPSS score.

Description: Tumor necrosis factor (TNF)-α, a potent stimulus of nuclear factor-κB (NF-κB), is up-regulated in myelodysplastic syndrome (MDS). Here, we show that bone marrow mononuclear cells (BMMCs) and purified CD34+ cells from patients with low-grade/early-stage MDS (refractory anemia/refractory anemia with ring sideroblasts [RA/RARS]) have low levels of NF-κB activity in nuclear extracts comparable with normal marrow, while patients with RA with excess blasts (RAEB) show significantly increased levels of activity (P = .008). Exogenous TNF-α enhanced NF-κB nuclear translocation in MDS BMMCs above baseline levels. Treatment with arsenic trioxide (ATO; 2-200 μM) inhibited NF-κB activity in normal marrow, primary MDS, and ML1 cells, even in the presence of exogenous TNF-α (20 ng/mL), and down-regulated NF-κB-dependent antiapoptotic proteins, B-cell leukemia XL (Bcl-XL), Bcl-2, X-linked inhibitor of apoptosis (XIAP), and Fas-associated death domain (FADD)-like interleukin-1β-converting enzyme (FLICE) inhibitory protein (FLIP), leading to apoptosis. However, overexpression of FLIP resulted in increased NF-κB activity and rendered ML1 cells resistant to ATO-induced apoptosis. These data are consistent with the observed up-regulation of FLIP and resistance to apoptosis with advanced MDS, where ATO as a single agent may show only limited efficacy. However, the data also suggest that combinations of ATO with agents that interfere with other pathways, such as FLIP autoamplification via NF-κB, may have considerable therapeutic activity.