ALBERT

Description: Abstract 349 Natural killer (NK) cells are vital in the control of viral infection and malignancy, in particular AML. Affinity strength between NK receptors and their HLA ligands control both NK effector function and degree of NK inhibition. Differences in binding affinity between allotypes of the NK receptor KIR3DL1 and allotypes of its ligand HLA-Bw4 depend on the expression levels of the receptor and the amino acid residue at position 80 in the ligand. Because receptor-ligand affinities are associated with differences in HIV control, we hypothesized that different affinities between donor KIR3DL1 and donor-recipient HLA-Bw4 allotypes would impact the risk for AML relapse following allogeneic hematopoietic stem cell transplantation (HCT). Methods: We evaluated 299 AML patients who underwent allogeneic HCT from an unrelated donor between 1995 and 2002. Clinical data, HLA allotyping, and donor DNA were provided by the CIBMTR. KIR3DL1 allotyping was executed using PCR- and sequence-based methods. Donors were segregated into those with high-, low- and null expressing KIR3DL1 allele groups [3DL1-H (n=130), 3DL1-L (n=69), 3DL1-N (n=82)] and HLA-B allele groups (Bw6/Bw6, Bw4-I80, Bw4-T80). 3DL1-N genotypes are predictive of poor surface expression and were analyzed separately. Patients and donors were matched at 9 or 10 HLA loci in all cases, with only 3 donor-patient pairs mismatched for HLA-Bw4 ligands. Affinity cohorts were compared using Cox regression for the time-to-event outcomes of relapse and overall mortality (OM). Kaplan-Meier estimates of overall survival and cumulative incidence estimates of relapse were obtained. Results: Recipients of 3DL1-H and 3DL1-L donors were analyzed for high and low-affinity associations with post-HCT AML relapse. Among patients with a 3DL1-H donor, those transplanted from donors with the low-affinity KIR/HLA allotype combination 3DL1-H/Bw4-T80 had lower risk of relapse when compared to those with the high-affinity 3DL1-H/Bw4-I80 combination (HR 0.22; p=.003, Table) and even moreso when compared to the extra-high affinity combinations of 3DL1-H with Bw4-I80-B*2702 or B*57 (HR 0.10; p

Description: Background HDCy has been used post SCT in both haploidentical and matched sibling donor SCT for gvhd prophylaxis following non myeloablative conditioning as described by the John Hopkin's group. MD Anderson group (Ciurea et al: BBMT 18:1835-1844, 2012) has reported the feasibility of HDCy post a more intense HDMel based conditioning in haploidentical setting. There is no published data on the outcomes of this conditioning in matched and partially matched alloSCT. Methods We retrospectively analyzed the outcomes of all patients who HDMel based conditioning followed by HDCy post SCT at our institution. Results 18 patients (12 males; 6 females) with a median age of 52 (range 25-70) years were identified from the database. Disease category was plasma cell malignancy (n=5); AML (n=4); ALL (n=4); MDS/MPD (n=3) and NHL/CLL (n=2). Nine patients had active disease at the time of SCT. One patient had a prior allogeneic SCT and 4 patients had prior auto SCT. Preparative regimen was fludarabine (25mg/m2 x5) HDMel (100-140 mg/m2) and thiotepa (5-10 mg/kg). One patient with lymphoma received Zevalin instead of thiotepa. HDCy (50mg/kg) was given on days 3 and 4 post SCT. HLA mismatched patients also received horse ATG (20mg/kg x 3). Additional gvhd prophylaxis was sirolimus in 14 patients and tacrolimus/mycophenolate in 4 patients. Stem Cell source was peripheral blood in all patients. HLA matching was 10/10 in 11, 9/10 in 6 and 5/10 in one patient. 15 donors were unrelated and 3 were siblings. Median CD34 cells infused were 5.3 x 10e6/kg range (3.4 -7.5). All patients engrafted with a median time to neutrophil engraftment of 19 days (range 15-23) and a median time to platelet engraftment of 25.5 days (range 14-138). Cumulative incidence of grade 2-4 acute gvhd was 38.9% and chronic gvhd was 16.6%. Day 100, 6 month and 1 year survival was 100%, 87% and 80% (Figure 1). The median follow-up for survivors is 306.5 days (range 81-935). Four patients have died (hemopagocytic syndrome - day 187; progressive disease - day 455; persistent disease/gvhd - day 126; perforated bowel/gvhd - day 167). Ten (55%) patients were taken off all immune suppression at a median of 93 days (range 56-215) post SCT with an estimated cumulative incidence of immune suppression withdrawal of 73.2% (95% CI: 27.1-92.8) in 215 days (Figure 2). Conclusion HDCy post HDMel based conditioning is feasible in matched and partially matched allo SCT recipients with high risk hematological malignancies. This regimen delivers significant dose intensity and results in acceptable early mortality and high incidence of immunosuppression withdrawal early post SCT. Disclosures: Off Label Use: Most drugs in this study are off label for their use in stem cell transplant.

Description: Abstract 4299 Previous reports have shown that infusion of NK cells from a MHC mismatched donor can mediate an anti-leukemic effect in the recipient of an allogeneic hematopoietic stem cell transplant (HSCT). In this phase I study, we infused increasing numbers of allogeneic NK-cell enriched mononuclear cells (NK-MNC) from a MHC haplo-mismatched relative into patients who had recently undergone autologous stem cell transplant. We sought to determine whether infusion of mismatched, allogeneic NK-MNC cells was safe without concern for GvHD or graft rejection, and also whether cell collection, processing and patient treatment could feasibly be performed at different cities across the US. MNC were obtained by apheresis from healthy haploidentical relatives by one steady-state leukapheresis of 2–4 hours on day 1, and were sent by air courier to the PACT* cell processing facility (University of Minnesota) where immunomagnetic depletion of CD3 cells (Miltenyi CliniMACS) was performed. The CD3-depleted cells were then cultured in X-VIVO 15, without gentamicin and phenol red (Cambrex BioScience, Walkersville, Maryland), supplemented with 1000 U/mL IL-2 (Chiron Corporation, Emeryville, CA) and 10% human heat-inactivated AB serum (Valley Biomedical Products and Services, Inc., Winchester, VA) in VueLife™Teflon® (FEP) bags (American Fluoroseal Corporation, Gaithersburg, MD). The resulting NK-MNC products were then returned by air courier at approximately body temperature to Boston for infusion on day 3. Twelve patients (age range: 27–63) within 49–191 days (median 106 days) after autologous HSCT were treated at four different dose levels of NK-MNC: 105, 106, 107 and 2×107 NK-MNC/kg. No logistical transport issues between Boston and the processing facility in Minnesota occurred. Release criteria (〈 5 × 105 CD3+ cells/kg, 〉 20% CD3-/CD56+ cells, viability 〉70%, Gram stain – no organisms) were met in all but one case. Side effects after infusion occurred only at the higher dose level of NK-MNC infusion: rigors (n=2) and muscle aches (n=1), responsive to meperidine. None of the patients required discontinuation of NK-MNC infusion. No GvHD or marrow suppression occurred. Chimerism analysis (STR-PCR) from leukocytes on peripheral blood samples collected 24 hours after the NK-MSC infusion failed to detect donor-derived NK-MNC in the recipients (sensitivity: 3 %). Given these results, we conclude that long-distance transport of manipulated NK-MNC products between treatment and processing centers is feasible and reliable, clearly supporting the premise of PACT, and that CD3-depleted allogeneic NK-MNC from a MHC-mismatched relative can be safely administered to recipients of a recent autologous HSCT. This project has been funded in part by the National Heart, Lung, and Blood Institute, National Institutes of Health, under the University of Minnesota Contract [] N01-HB-37164 and HHSN268201000008C *PACT: Production Assistance for Cellular Therapies Disclosures: No relevant conflicts of interest to declare.

Description: Key Points Donor age and donor-recipient HLA match predict survival after hematopoietic cell transplantation.

Description: Background: Success of single unit UD-CBSCT has been limited by graft failure, delayed engraftment and high early mortality. Preparative regimen of Busulfan with TF and horse ATG has reduced early mortality and improved engraftment in single unit UD-CBSCT in adults (Sanz. BMT 2012: 47; 1287-1293). M with TF and r-ATG has previously been used as a preparative regimen in double expanded UD-CBSCT in adults (De-Lima. NEJM 2012: 367; 2305-2315). Outcomes of this regimen will be of interest in single unit UD-CBSCT. Methods: We retrospectively analyzed the outcomes of all patients that underwent UD-CBSCT from single unit using MTF-rATG conditioning at UMass Memorial Medical Center. Results: Twenty five underwent single unit UD-CBSCT from January 2009 to June 2014. There were 15 males and 10 females. The median age was 63 years (range, 28 -81) and median weight was 68.9 kg (range, 58.9 - 119). Nine patients (36%) were over age 65 years. Diagnosis was AML/MDS (n= 18), CLL (n= 2) and others (n=5)- ALL/Aplastic Anemia/MM/NHL/Blastic NK cell malignancy. Disease status CR1 (n=11), CR2 (n=1) and persistent disease (n=13). Four patients had undergone a prior autologous SCT. Preparative regimen consisted of T (5-10 mg/kg) day -7, F (30 mg/m2) from day -6 to -2, M (100-140 mg/m2) day -1 and r-ATG (3 mg/kg). Graft versus host disease (gvhd) prophylaxis consisted of mycophenolate mofetil (day -1 to 56) and tacrolimus (level 5-15 ng/ml) starting day -1. Tacrolimus was replaced in 2 patients: Sirolimus (n=1) and Cyclosporine (n=1). HLA matching was 6/6 (n=1), 5/6 (n=1) and 4/6 (n=23). The median total nucleated cell (TNC) dose based on pre-cryopreserved sample was 3x10e7/kg (range, 1.9 - 5.3). The median TNC and CD34 cells infused was 2.5x10e7/kg (range, 1.3-4.2) and 1.13x10e5/kg (range, 0.16-3.05) respectively. Day 100 mortality was 16% (CI,6-37%). Cumulative incidence of neutrophil engraftment (NE) was 92% (CI, 62- 99%) and that of platelet engraftment (PE) was 84% (CI, 57- 95%) Figure 1 & 2.The median time of NE was 19 days (range, 13-37) and that of PE was 40 days (range, 24-73). All 23 patients surviving beyond day 10 engrafted their neutrophils. “Transplant Success" defined by a composite end point (NE by day 26, PE by day 60 and survival at day 100) was 60% (CI,38% -77%). The incidence of acute gvhd (I &II only) was 18% (CI,6-41%) and that of chronic gvhd was 25% (CI10-49%). 9 patients are currently alive at a median followup of 932 days (range, 97-1875 ) .All survivors are gvhd free and off immune suppression.The 2 year overall survival (OS) based on Kaplan Meier estimate is 36 %(CI,18-55%). Figure 3 Discussion: Preparative regimen of MFT-rATG results in excellent engraftment, low early mortality and acceptable “Transplant Success” in single unit UD-CBSCT in older adults. Our outcomes in high risk older adults compare favorably to other studies using “double cord” or “cord blood expansion” strategies. Figure 1 Figure 1. Figure 2 Figure 2. Figure 3 Figure 3. Disclosures Nath: Celgene: Consultancy, Honoraria. Off Label Use: Thiotepa,Melphalan,rabbit ATG,Fludarabine, mycophenolate mofetil All these have been used in preparative regimens and gvhd prophylaxis for allogeneic stem cell transplantation. Cerny:Incyte: Consultancy, Honoraria; Ariad Pharmaceuticals: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria.

Description: Background: Allo-SCT is a curative option for patients with AML and MDS. It is unclear whether there is an upper age limit for Allo-SCT. CIBMTR showed similar outcomes for patients older than 65 years after Allo-SCT (McClune et al J Clin Oncol 28:1878-1887). A single center report of 54 patients (70 - 75 years) established the feasibility of Allo-SCT in patients over age 70 (Brunner et al Biol Blood Marrow Transplant 19:1374-1380). There is no published data on Allo-SCT in patients older than 75 years. Methods: Retrospective analysis was performed on all patients with diagnosis of AML or MDS who underwent an Allo-SCT after their 75th birthday at UMass Memorial Medical Center on an IRB approved protocol. Results: 14 patients were identified from the database. Median age at transplant was 78.4 years (range 75.2 - 83.6). Diagnosis was AML (N=10) and MDS (N=4). Disease status at SCT for AML patients was CR1 (N=6), ≥ CR2 (N=2) and relapse (N=2). Source of stem cell was peripheral blood (PB) (N=11) and cord blood (CB) (N=3). Median time from diagnosis to SCT was 7 months (range 3 - 98). Karnofsky score (KS) at SCT was 90 (N=5) and 80 (N=9). Three patients had prior autologous SCT. Source of stem cells was peripheral blood (PB) (N=11) and cord blood (CB) (N=3). Donors were mostly unrelated (N=13) with one being mismatched related (N=1). For PB recipients the HLA matching was 10/10 in 7 patients and 9-11/12 in 4 patients. CMV serostatus was neg/neg (N=2), pos/pos(N=4) and pos/neg (N=7). ABO mismatch was major (N=1) and minor (N=6). Conditioning regimen was reduced intensity in 13/14 recipients. All three CB recipients received Melphalan (Mel) based conditioning (Thio/Flu/Mel 100-140mg/m2). Conditioning for PB recipients was Busulfan(Bu) based (N=6) and Mel (dose 50 - 140mg/m2)based (N=5). Graft versus Host Disease (gvhd) prophylaxis was Tacrolimus (Tac) with Mycophenolate mofetil (MMF) for all CB-SCT recipients Flu/Bu-2 recipients. All Mel based PB-SCT recipients received post-transplant Cyclophosphamide (days 3, 4) with Sirolimus. HLA mismatched patients also receive Tac. 11/14 patients received ATG. All PB recipients engrafted their neutrophils at a median of 16 days (range 13-21). 10/11 patients engrafted their platelets at a median of 18 days (range 0-32). One CB recipient died on day 10 before engrafting. Other two CB recipients engrafted their neutrophils on day 14 and platelets on days 33 &37. Day 100, 1- year and 5 - year overall survival for the entire cohort was 70.7% (95% CI 39.4-87.9), 53% (95% CI 23.3-75.9) and 22.1% (95% CI 3.8 -49.9) respectively. Two patients developed grade III and 3 patients developed grade II acute gvhd. Chronic (limited) gvhd was seen in one patient only. 9 patients died at a median of 264 days (range 10 - 802) post SCT. There were no deaths due to disease progression. Three patient are currently surviving beyond 2 years. Two of these patients are immune suppression free, gvhd free and live alone with a KS of 100. 3 out of 4 patients over age 80 years survived more than 2 years. Conclusion: Allo-SCT is feasible in selected patients over the age of 75. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.