ALBERT

Description: Abstract 4902 Introduction Cytogenetics and fluorescent-in situ hybridization (FISH) are important outcome predictors in multiple myeloma (MM). There were only few small studies that investigated prognostic implication of FISH and/or conventional karyotyping in Korean MM patients. We investigated the incidences and prognostic significances of chromosomal abnormalities detected by FISH and/or conventional karyotyping among Korean MM patients. Patients and Methods We collected data of patients from Korean Myeloma Registry and performed retrospective analysis. We compared the survival of patients with chromosomal abnormalities and other clinical findings. Results From 2000 to 2009, total of 801 newly diagnosed myeloma patients were enrolled in this study. Median age of patients was 62 years. Median overall survival was 82 months, and median follow up of time was 92 months. Among the patients who had conventional karyotype analysis, 17.1% were complex karyotype, followed by del13q (7.4%), hyperdiploidy (7.6%), hypodiploidy (3.0%), and t(11;14) (3.9%). Among the patients who had FISH analysis, 22.8% were del 13q, followed by t(11;14) (18.2%), t(4;14) (13.7%), del17p (11.8%) and t(14;16) (5.9%). Univariate analyses revealed that complex karyotype (p

Description: Background: Autologous stem-cell transplantation (ASCT) after high-dose chemotherapy is regarded as the standard therapeutic approach for multiple myeloma (MM) even if virtually all patients ultimately relapse following this procedure. Recently, tandem ASCT significantly improved overall survival (OS) and event-free survival (EFS) compared with single ASCT. Another strategy is to use reduced-intensity allogeneic stem cell transplantation (RISCT) earlier in the course of disease in chemosensitive patients. In the current study, we retrospectively analyzed the outcomes after a planned tandem ASCT or RISCT in the patients who previously underwent ASCT. Patients and methods: One-hundred twenty-six patients who received a high dose (140 to 200 mg/m2) of melphalan as the conditioning regimen of the first ASCT were analyzed. Ninety-six patients (median age, 50.5 years) received a second ASCT, whereas 30 patients (median age, 46.5 years) underwent a RISCT (related in 28 patients and unrelated in 2 patients). The median interval between the first and second transplant was 131 days in tandem ASCT group and 157.5 days in RISCT group. The conditioning regimen for the tandem ASCT and RISCT consisted of high-dose melphalan ± total body irradiation (TBI) and fludarabine + melphalan or TBI, respectively. The two groups were evenly matched with regard to other disease characteristics. Results: After a median follow-up of 664 days (range, 143–2904) from the first ASCT, the median event-free survival (EFS) and overall survival (OS) in all 126 patients were 878 days and 1838 days, respectively. The median EFS in the second ASCT vs. RISCT group were 844 days (95% CI, 714–973) and 1342 days (95% CI, 813–1870), respectively (P=0.262). The median OS in the tandem ASCT vs. RISCT group were 2160 days (95% CI, 1847–2832) and 1575 days (95% CI, 1202–1947), respectively (P=0.132). Disease-related mortality was not significantly different between the second ASCT vs. RISCT groups (73.3% vs. 60.0%, P=0.325) as well as treatment-related mortality between the 2 groups (26.7% vs. 40%, P=0.358). On multivariate analysis, an achieving a good response (≥ VGPR) after the induction treatment predicted a better EFS compared to a poor response (≤ PR) (RR; 0.245, P=0.01). A good response after first ASCT or the second transplant was associated with a better EFS by univariate analysis but not by multivariate analysis (RR; 0.927, P=0.830 or RR; 0.772, P=0.453, respectively). Conclusion: In this retrospective analysis, ASCT followed by RISCT was not superior to the tandem ASCT, either EFS or OS. Disease-related deaths were not different between the 2 groups. Patients whose disease is sensitive to induction chemotherapy and who obtain a good response after the induction treatment benefited the most from this tandem transplant therapy.

Description: Background The treatment of localized extranodal NK/T-cell lymphoma (ENKTL), nasal type has shifted to non-anthracycline-based intensive chemotherapy with radiotherapy since the poor response of ENKTL to anthracycline due to the expression of a multidrug-resistant (MDR) p-glycoprotein was proven. We previously proposed concurrent chemoradiotherapy (CCRT) followed by chemotherapy which is not affected by MDR and reported a significant improvement of outcomes of localized ENKTL. Based on our accumulated data, we designed a new treatment protocol. First, we added tri-weekly administration of L-asparaginase to reduce the probability of systemic progression during CCRT. Second, we designed MIDLE (methotrexate, ifosfamide, etoposide, dexamethasone, and L-asparaginase) according to previous excellent outcomes of methotrexate-containing regimens such as SMILE (dexamethasone, methotrexate, ifosfamide, L-asparaginase, etoposide) and MLD (methotrexate, L-asparaginase, dexamethasone). Methods The treatment scheme of CCRT consisted of radiation 40 Gy and weekly administration of cisplatin 30 mg/m2 (total: 4 doses). During the CCRT, tri-weekly intravenous (IV) administration of 4,000 IU of Escherichia coli L-asparaginase was done. The chemotherapy, MIDLE (methotrexate 3g/m2 on day 1, etoposide 100mg/m2, Ifosfamide 1000mg/m2 on day 2-3, dexamethasone 40mg on day 1-4, and L-asparaginase 6000IU/m2 IV on day 4, 6, 8, 10) was repeated every 28 days up to 2 cycles. All patients provided informed written consents and this trial was registered at www.ClinicalTrials.gov(NCT01238159). Results Twenty-eight patients with stage IE/IIE ENKTL were enrolled, and the median age was 51 years (range, 30–77 years). 24 patients were male while only four patients were female. Twenty-two patients were stage IE and six were IIE. All patients completed CCRT, which resulted in 92.9% of overall response rate including 20 complete responses and 6 partial responses. One patient showed stable disease after CCRT whereas the other patient progressed. No grade 3 or 4 hematologic toxicity was found during CCRT. However, grade 3 non-hematologic toxicities included bilirubin elevation (n = 4), mucositis (n = 1), and nausea/vomiting (n = 6). After the completion of CCRT, 23 patients entered the MIDLE chemotherapy as five patients including one disease progression and four cases of withdrawal could not receive MIDLE. All patients achieved complete response after they completed the planned two cycles of MIDLE chemotherapy whereas two patients dropped out after their first cycle due to non-hematologic toxicity. The final complete response rate of patients enrolled was 92.9% (26/28). The major toxicity of MIDLE was grade 3/4 leucopenia, and the non-hematologic toxicity included mucositis and nausea/vomiting. The hepatic toxicity-associated with L-asparaginase was frequent. However, the majority of the hepatic toxicities were grade 1 or 2. With the median potential follow-up of 25 months (95% confidence interval: 19 – 31 months), four patients relapsed. Conclusion L-asparaginase plus concurrent chemoradiotherapy followed by MIDLE chemotherapy can be an effective treatment strategy with acceptable toxicity in stage I/II extranodal NK/T-Cell lymphoma, nasal type. Disclosures: Kwak: celgene: Research Funding.

Description: Abstract 2683 Background Secondary central nervous system (CNS) involvement in diffuse large B-cell lymphoma (DLBCL) includes CNS relapse or CNS involvement with systemic disease progression. Although many publications have provided information regarding the incidence and risk factors for CNS involvement in DLBCL, its incidence reported across those studies varies widely. It might be related with that the majority of data were from retrospective analyses. Furthermore, the role of CNS prophylaxis for DLBCL has been challenged, especially in the era of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). As a result, this rare but fatal clinical problem still remains a therapeutic dilemma in the management of DLBCL. In this study, we prospectively explored the risk factors of CNS involvement and the clinical impact of screening evaluation for CNS involvement. Methods We analyzed the incidence of secondary CNS involvement in pathologically confirmed DLBCL patients enrolled in the Prospective Cohort Study with Risk-adapted Central Nervous System Evaluation in Diffuse Large B-cell Lymphoma (PROCESS study, NCT01202448). Patients should be treated with at least one cycle of R-CHOP, and provide written informed consents. We assessed the risk of CNS involvement based on previously reported risk factors: serum LDH elevation, the number of extranodal involvements, serum albumin, bone marrow invasion, HIV positivity, the involvement of testis, breast, paranasal sinus, bone, retroperitoneal lymph nodes, orbit, and epidural space. If patients had any of these risk factors, they underwent CSF study to screen the CNS involvement at diagnosis. If the results were abnormal, additional studies including brain MRI could be done depending on physicians' decision. CNS prophylaxis was done with intrathecal chemotherapy with methotrexate for patients who had positive findings of screening evaluation or were determined to have a risk of CNS involvement based on physicians' decision. Results 564 patients were enrolled between 2010 and 2012 from 26 institutions belonged to the Consortium for Improving Survival of Lymphoma (CISL). They were prospectively monitored with the median follow-up duration of 10.5 months. The median age was 59.5 years old (range 20–89 years), and approximately a half of patients had Ann Arbor stage III/IV (n = 276, 48.9%) and 193 patients involved two or more than two extranodal sites (34.2%). Based on the International Prognostic Index (IPI) risk, 192 patients belonged to high or high-intermediate risk (34%). Among patients (n = 368) who had at least one of risk factors for CNS involvement, 243 patients underwent CNS evaluation, and the evidence of CNS involvement was found in16 patients including positive cytology (n = 11), and brain parenchyma lesion (n = 5). The other 78 patients showed equivocal results of CSF analysis including the presence of atypical cells (n = 17). Intrathecal prophylaxis was done for 51 patients whereas high dose methotrexate chemotherapy was combined with R-CHOP for patients with brain lesion. During follow-up, 14 cases of additional CNS involvement including brain parenchyma (n = 8), leptomeningeal (n = 5), and ocular invasion (n = 1) were observed. The median time to CNS event in these 14 patients was 7.5 months (range 1.2 – 15.9 months). Thus, 30 cases of secondary CNS involvement were documented in our study population at the time of analysis (5.3%) including 16 cases at diagnosis and 14 cases during follow-up. The univariate analysis for evaluation of risk factors demonstrated serum LDH, the number of extranodal involvements, bone marrow invasion, and the involvement of retroperitoneal lymph nodes, breast, paranasal sinus and orbit were significantly associated with CNS involvement. The high/high-intermediate risk of IPI was also predictive of CNS involvement (P 〈 0.05). However, in the multivariate analysis, bone marrow invasion and the involvement of breast, paranasal sinus and orbit were independently predictive for CNS involvement. Conclusions The incidence of secondary CNS involvement in DLBCL patients treated with R-CHOP was around 5%, and a half of cases had the evidence of CNS involvement at diagnosis. Considering a particular risk of CNS involvement of disease-related factors, risk-adapted active screening against CNS involvement may help to improve treatment outcome of patients with DLBCL. Disclosures: No relevant conflicts of interest to declare.

Description: The essential pathogenic mechanism in acute myeloid leukemia (AML) is a heterogeneous group of malignant diseases arising as the result of progressive genetic damage occurring in hemopoietic progenitor cells. Mcl-1 (myeloid cell leukemia-1), an antiapoptotic protein of the Bcl-2 family, is located on chromosome 1 and has three exons and two introns. Overexpression of Mcl-1 delays apoptosis induced by cytotoxic agents, c-myc overexpression, and growth factor withdrawal in hematopoietuc cells. To evaluate the association between genetic variants of Mcl-1 gene and risk of AML, we genotyped two polymorphisms in promoter of Mcl-1[rs3738484; −324 C〉A and rs3831987; −284 insertion(6bp or18bp)/deletion]. A case-control study of 728 controls and 660 cases was conducted in Chonnam National University Hwasun Hospital, Korea. The Mcl −324 CA and combined CA/AA genotype was significantly associated with a decreased risk for AML [odds ratio (OR) CA = 0.75; 95% confidence interval (CI) = 0.60–0.95; ORCA/AA = 0.76; 95% CI = 0.61–0.96]. There was no association with the Mcl -284 insertion/deletion and AML. The haplotype A-ins18bp is significantly associated with the risk of AML. Using subjects with the haplotype A- del, the OR of haplotype A-ins18bp is 5.87 (95% CI 1.7–20.06 p= 0.006). Our results suggest that antiapoptotic protein, Mcl-1 polymorphism may influence susceptibility to AML.

Description: Xenobiotic-metabolizing enzymes influence the susceptibility to malignancies as well as prognosis by causing chemotherapy resistance. We analyzed genetic polymorphisms of glutathione S-transferases T1 and M1 (del GSTT1 and del GSTM1) and NAD(P)H quinone-oxoreductase (NQO1 C609T) to evaluate the association and risk of acute myeloid leukemia (AML). A large-scale population-based, case-control study of 1700 controls and 663 cases was conducted in Chonnam National University Hwasun Hospital, Korea. GST T1 null genotype was associated with increased risk for AML [odds ratio (OR) = 1.20; 95% confidence interval (CI) = 1.003–1.45, p=0.047]. GST M1 null genotype was highly associated with a decreased risk for AML (OR= 0.38; 95%CI = 0.31–0.46, p〈 0.0001). Analysis of the NQO1 C609T polymorphism failed to show an association with AML, although a near significant increase was also found in NQO1 609GG genotype (OR= 1.30; 95%CI = 0.54–4.77, p=0.06) Our results suggest an association of extensive GST with an increased or decreased risk for AML, possibly by an increase in the metabolic activation of chemical carcinogens or linkage to another cancer-causing gene. Inconsistent result in other studies may be due to geographical differences in the type of environmental carcinogens to which different populations are exposed.

Description: Multiple Myeloma (MM) fits in the group of plasm cell disorders characterized by neoplastic proliferation of single clone of plasma cell engaged in the production of a monoclonal immunoglobulin. The cause of MM is unclear, but a genetic predisposition may play a role and cytogenetic abnormalities are considered to be the most important prognostic factor. The proteomic analysis of MM emerges as a key complement to gene expression profiling, primarily because regulation of protein expression can buffer the magnitude of changes occurring at the gene transcription level. In the present study, to identify biomarkers of initial diagnosis, detection of relapse, monitoring for minimal residual disease and prognostic marker in MM by a lesser invasive method, serum proteins reflecting alteration in their proteomes were analyzed. We compared two-dimensional electrophoresis patterns of human sera of twelve patients with multiple myeloma with that of normal twelve subjects. The differentially expressed spots were identified by matrix-assisted laser desorption/ionization-time-of flight (MALDI-TOF) and electrospray ionization quadupole time of flight (ESI-Q-TOF) mass spectrometry. We identified several proteins altered in sera of MM patients. These results suggest that these proteins can be used as a lesser invasive diagnostic, monitoring and prognositic biomarkers of MM if further studies were done.

Description: Introduction : Myelo-monocytic cells expressing CD11b are involved in angiogenesis, but their specific roles and underlying mechanisms are unclear. CX3CR1 is the only known receptor for fractalkine (Fkn). CD11b+CX3CR1+ cells isolated from ischemic muscles expressed F4/80, which is a common marker for mouse macrophages (Tissue (T)-CD11b+CX3CR1+ macrophages). T-CD11b+CX3CR1+ macrophages exert pro-angiogenic effect by platelet factor-4 (PF-4) production. PF-4 did not promote angiogenesis by itself but magnified the angiogenic activity of VEGF. Although T-CD11b+CX3CR1+ macrophages show definite pro-angiogenic effects, their clinical implementation is limited because they require muscle excision for cell harvesting. Therefore, we focused on angiogenic potential of more accessible bone marrow (BM)-CD11b+CX3CR1+ monocytes, because the CD11b+CX3CR1+monocytes migrate from BM into ischemic muscles via Fkn-mediated chemotaxis and differentiate into macrophages upon tissue damage. Materials and methods: CD11b+CX3CR1+cells were isolated by MoFlo™ XDP Cell Sorter (Beckman Coulter, Brea, CA). Isolated CD11b+CX3CR1+ cells were fixed and stained with anti-PF-4 Ab with PE-conjugated IgG for immunofluorescence staining. For aortic tissue sprouting assay, thoracic aortas were embedded in Collagen Type-1. Aortic segments were incubated with CD11b+CX3CR1+ monocytes in the presence or absence of Fkn, and their conditioned medium (CM) at 37℃ in a humidified 5% CO2 atmosphere with triweekly media replacement. For Fkn treatment, CD11b+CX3CR1+monocytes were incubated with Fkn (50ng/mL) for 30 minutes. Morphometric analysis of sprouting was performed using Image J software (National Institute Health, Bethesda, MD, USA). Results: T-CD11b+CX3CR1+ macrophages greatly increased sprouting from mouse aortic tissue segments, while T-CD11b+CX3CR1- macrophages showed only modest effects (p

Description: Chronic myeloid leukemia(CML) is a clonal myeloproliferative disorder and increased angiogenesis in bone marrow is a feature of CML. Vascular endothelial growth factor(VEGF) is a potent angiogenic peptide and microvessel density(MVD) is increased in bone marrow of CML. In this study, the effect of imatinib mesylate therapy on angiogeneisis was investigated and compared with allogeneic bone marrow transplantation(BMT) with philadelphia chromosome positive/BCR-ABL+ CML in first chronic phase. Immunohistochemical staining for detecting VEGF protein was performed by labeled avidin-biotin method on the formalin-fixed and paraffin embedded bone marrow biopsy samples of 10patients of allogeneic BMT, 20patients of imatinib mesylate therapy and 10normal control. Initial and sequential, after at least 12 months of therapy, bone marrow biopsy examed and all patients achieved complete cytogenetic remission. Microvessel was scored in at least 3 areas(*200 fields) of the highest MVD in representative sections of each bone marrow biopsy specimen using immunohistochemistry for CD32 antigen. Patients with Imatinib mesylate therapy and allogeneic BMT induced a significant reduction of MVD (normalization in comparison with controls). MVD was no significant difference between the patients with imatinib therapy and allogeneic BMT. VEGF was mainly expressed myeloid progenitors and less abundantly megakaryocytes and mature granulomonocytic cells. Expression of VEGF, it was significantly decreased in patients with Imatinib mesylate therapy and allogeneic BMT(normalization in comparison with controls). VEGF expression was no significant difference between the patients with imatinib therapy and allogeneic BMT. First line therapy with imatinib mesylate was normalization of bone marrow vascularity compared with allogeneic bone marrow transplantation of CML in first chronic phase.

Description: Abstract 2021 Background: High dose chemotherapy followed by autologous stem cell transplantation (ASCT) has become the standard approach for relapsed or high risk non-Hodgkin's lymphoma (NHL). Several different high dose therapy (HDT) conditioning regimens have been used for non-Hodgkin's lymphoma (NHL), such as BEAM (carmustine, etoposide, cytosine arabinoside, melphalan), BEAC (carmustine, etoposide, cytosine arabinoside, cyclophosphamide), and CBV (cyclophosphamide, carmustine, etoposide). Carmustine is an active drug in the HDT of NHL but the supply of carmustine is limited in some countries including Korea. Intravenous busulfan containing regimens as conditioining regimen have been used for both allogeneic and autologous stem cell transplantation in patients with hematologic and non –hematologic malignancies. The purpose of this prospective multicenter phase II study was evaluate the efficacy and safety of iv busulfan/melphalan/etoposide regimen as a conditioining regimen for high dose chemotherapy in the patients with relapsed or high risk NHL. Methods: Patients with relapsed or primary refractory NHL or chemosensitive high risk NHL underwent high dose chemotherapy followed by ASCT at 13 centers in Korea. The conditioning regimen consisted of iv busulfan 3.2mg/kg/day i.v. on days −8, −7 and −6, etoposide 400mg/m2/day i.v. on days −5 and −4 and melphalan 50mg/m2/day i.v. on days −3 and −2. Results: Fifty one patients were enrolled onto the study. Main subgroups were DLBCL (n=25, 49%) and T cell lymphoma (n=19, 37%). At the time of ASCT, the disease status of patients was as follows: 13 patients were high risk in remission, 16 were primarily refractory to inducton therapy, 15 patients were in chemosensitive relapse. All patients had successful stem cell engraftment with a median time to neutrophil recovery of more than 500/mm3 of 10 days (range, 2 to 30 days). Platelet recovery of more than 20,000/mm3 was seen after a median of 10 days (range, 2 to 51 days) with delayed recovery in one patient. Treatment related toxicities included nausea/vomiting in 28 patients (55%), diarrhea in 28 patients (55%) and mucositis in 33 patients (65%), which were grade I or II in the majority of cases. Grade I/II hepatic toxicities occurred in 24% (n=12) and grade III in 6% (n=3). There were no VOD and treatment related death. The median duration of hospitalization for ASCT was 30 days (range, 12 to 80 days). Forty one patients (80%) achieved a complete response 1 month after ASCT, while three patients showed progressive disease. At a median follow up of 14.7 months, 21(41%) patients exhibited a relapse or progression, while 11 patients had died of disease and one patient had died of heart failure. The estimated 2-year overall and progression free survival for all patients was 64% and 40%, respectively. Conclusion: This preliminary analysis suggests that conditioning regimen of i.v. busulfan/melphalan/etoposide would be well tolerated and effective in patients with relapsed or high risk NHL. Accordingly, this regimen may be regarded as an important treatment option to substitute for BEAM regimen. Disclosures: Lee: Novartis: Research Funding.