ALBERT

Description: Abstract 3034 Despite a large number of unrelated donors (UD), not more than 30% of patients who have activated a donor search, undergo an allogeneic UD stem cell transplant. HLA haploidentical family members are being increasingly considered as an alternative donors, both using T cell depleted or T cell replete grafts. Post-transplant high dose cyclophosphamide (PT-CY), introduced by the Baltimore group, has shown very promising results following non myeloablative conditioning regimens. We are now reporting 50 patients with high risk hematologic malignancies, who received a myeloablative regimen, followed by unmanipulated haploidentical bone marrow transplant (hBMT) and PT-CY. The myeloablative conditioning consisted of thiotepa (10 mg/kg), busulfan (9,6 mg/m2̂), fludarabine (150 mg/m2̂)(n=35), or total body irradiation (9,9–12 Gy), fludarabine (120 mg/m2̂) (n=15). The median age was 42 years (18–66); 23 patients were in remission and 27 had active disease; 10 patients were receiving a second allograft. Graft versus host disease (GvHD) prophylaxis consisted in PT-CY on day+3 and +5, cyclosporine (from day 0), and mycophenolate (from day +1). The median nucleated cell dose was 3.6 ×108̂/kg (range: 1,4 – 7,7). The median time to neutrophil counts of 〉0.5×109/L was 18 days (range, 13–30 days) and to platelet counts of 〉20×109/L 23 days (range, 14 – 58 days), respectively. There was no correlation between infused number of nucleated cells and days of neutrophil engraftment. The cumulative incidence of engraftment was 90%for neutrophils and 86% for platelets. Three patients died before engraftment, and 2 patients had autologous recovery: 45 patients (90%) had full donor chimerism on day +30. The cumulative incidence of grade II-III acute GvHD was 12%, and of moderate chronic GvHD 10%. With a median follow up for surviving patients of 333 days (149–623), the cumulative incidence of transplant related mortality is 18%, and the rate of relapse 26%. The actuarial 22 months disease free survival is 68% for patients in remission and 37% for patients with active disease (p

Description: BACKGROUND Essential Thrombocythemia (ET) is a Philadelphia-negative chronic myeloproliferative neoplasm characterized by haemorrhagic and thrombotic complications. Haemorrhagic events and arterial and venous thrombosis, including microcirculation transient occlusions, are the major causes of morbidity in ET patients. The control of these events represents the goal of standard therapeutic approaches. MATERIALS AND METHODS We retrospectively analysed data about 107 ET patients who received diagnosis between January 1980 and June 2014. Median follow-up was 80 months,16 patients were lost during follow-up. The medium age at diagnosis was 60 years, with a prevalence of female (66 patients).We recorded adverse cardiovascular events at diagnosis and during follow-up, assessing whether cytoreductive ad antiplatelet therapy could reduce such events and improve quality of life. Finally, we evaluated the impact of additional cardiovascular risk factors. OBJECTIVES to observe incidence and kind of thrombotic events in patients affected by ET at diagnosis and during follow-up. RESULTS 30 patients (27.7%) had a history of thrombosis at diagnosis (8 transient cerebral ischemia, 7 myocardial infarction/unstable angina, among them 7 patients experienced a rethrombosis during follow-up. 16 patients (15%) developed a first thrombotic event, all patients were under cytoreductive treatment. 21 patients with a history of thrombosis had more than 60 years at diagnosis, 19 patients (63%) had at least one additional cardiovascular risk factor among arterial hypertension, dyslipidemia, diabetes, obesity, hyperuricemia and smoking. Median platelet count was 813000/mm3, leukocyte count greater was more than 10000/mm3 in half of patients. Evolution to acute leukemia/myelofibrosis occurred in 3 (2,7%) and 7 (6,5%) patients of total. CONCLUSIONS The occurrence of thrombotic events even in patients with good hematologic response of disease and during antiplatelet and cytoreductive therapy, indicates the presence of a residual risk of thrombosis. This risk is not yet fully clarified by retrospective studies published until now. Prospective studies will be useful to evaluate the role and the importance of comorbidity in these patients with long-prognosis, in order to optimize therapy, reduce cardiovascular events and improve quality of life Disclosures No relevant conflicts of interest to declare.

Description: BACKGROUND: Iron overload from chronic transfusion therapy can be extremely toxic and most patients (pts) do not receive adequate iron chelation therapy (ICT) despite evidence of transfusional iron overload (IOL). Deferasirox (DFX) is the principal option currently available for ICT in the management of IOL due to transfusion dependent anemia, such as in MDS pts. The most common adverse events (AEs) are gastrointestinal disorders, skin rash, elevations in liver enzymes levels and non-progressive transient increases in serum creatinine also in MDS pts, most of whom are elderly with significant comorbidities and side effects of other concomitant therapies. In order to achieve effective ICT with minimal toxicity in individual pts, regular monitoring to assess IOL and adverse effects of DFX treatment is essential. METHODS: The safety and efficacy of DFX were examined in a retrospective multicenter observational study of transfusion-dependent (TD) MDS pts with International Prognostic Scoring System (IPSS) low-or Int-1-risk. We included all pts treated with DFX up to 12 months, divided into two groups; the first one (group A) not under a multidisciplinary assessment, including pts not adequately treated, in terms of dosing and discontinuation of ICT and the second one (group B) with pts under multidisciplinary control. The DFX starting dosing was 10 mg/kg/die in all pts. The aim of our retrospective analysis was to assess the effectiveness of ICT in relation of dosing and right management of AEs. RESULT: We evaluated 45 MDS pts (12F/33M); 27 belonging to the group A and 18 to group B. The age was 74.2±8.8 and 77.3±4.8 respectively. The ECOG 0-1 was 85,1% in group A and 88,9% in group B. The transfusion episodes prior starting DFX were22.1±12.1 and 24.5±35.4 in the first and in the second group, respectively. The serum ferritin level at baseline was respectively 1285.1±489.6 ng/mL and 1452.6±748.1 ng/mL. The mean serum ferritin level increased from 1285.1+489.6 ng/mL to 1412.1+842.8 ng/mL in group A while decreased from 1452.6+748.1 ng/mL to 1166.1+ 723.4 ng/mL in group B. The rate of inadequate therapy, in terms of dosing and/or discontinuation ICT, was 85% in group A compared to 60% in group B (p= 0.086).The rate of severe SAE observed in all pts was 10%.The most common AEs were diarrhea, nausea, upper abdominal pain, serum creatinine increase. The positive hematological response rate was observed in 15% of all pts. CONCLUSIONS: The study showed that group B obtained advantage in terms of efficacy and toxicity. The difference between the two groups derived from the ability to manage comorbidities, concomitant therapies and AEs, in particular the rise in serum creatinine, the most common cause DFX discontinuation or dosing reduction. In this setting, the most important specialist was the nephrologist. In our multidisciplinary group experts in management of ICT were hematologist, internist, immune-hematologist and nephrologist. We shared how we monitored kidney function and managed a possible nephrotoxicity (table.2), in order to ensure DFX efficacy. Positive hematological responses were observed, and a subset of pts achieved transfusion independence. The timing of future multidisciplinary evaluation is set on 24 and 36 months, time in which we expect the best response to DFX therapy. Table 1. Ferritin trend group A (n27) group B (n18) Ferritin N mean±SD Median (range) N mean±SD Median (range) Baseline 27 1285.1±489.6 1134 (388-2099) 18 1452.6±748.1 1515 (160-3018) 3 months 22 1451.5±720.5 1247.5 (529-2791) 13 1312.7±909.8 1064 (521-3859) 6 months 23 1850.5±1079.1 1419 (374-4185) 11 1168.4±648.4 1300 (160-2409) 12 months 17 1412.1±842.8 1372 (111-3127) 9 1166.1±723.4 930 (277-2536) Table 2. Management of renal changes during therapy with DFX Creatinine and urine examination:1) in two successive determinations prior to initiation of therapy, then every month 2) in pts with other risk factors for kidney disease, every week for 1 month after start of DFX or dose increase and, subsequently, every month Changes in creatinine:1) increased by 33% in two successive determinations: reduce DFX dose of 5 mg/kg 2) progressive increase of creatinine: interrupt DFX and then re-challenge it at a lower dose with gradual increase if the clinical benefits outweigh the risks Disclosures No relevant conflicts of interest to declare.

Description: Abstract 2333 Introduction. Donor lymphocyte infusions (DLI) have been now used for 20 years in patients undergoing allogeneic hemopoietic stem cells transplants (HSCT). Initially DLI were only used in patients with chronic myeloid leukemia (CML) for the treatment of relapse. Subsequently DLI have been used in other disorders, and for different reasons, such as molecular relapse, mixed chimerism and also in prophylaxis programs. DLI are associate with a risk of Graft versus Host Disease (GvHD) and non relapse mortality (NRM). We have been using escalating doses of DLI for many years, and wanted to assess risk factors for GvHD and NRM. Patients. We analyzed 287 patients who received a total of 1288 DLI, for different reasons and at different intervals from transplant. The median number of DLI was 4 (1-15) the median interval between transplant and DLi was 282 dasy (1-4480), the median number of infused CD3 cells /kg of recipients body weight was 1×10^7 (1×10^3- 5×10^7). The diagnoses were chronic myeloid leukemia (n=78), acute leukemia (n=100), myelofibrosis (n=21), myelodisplastic syndrome (n=14), lymphoma (n= 35), other diagnosis (n=38). Median patients age was 40 (12-68). Statistical analysis. Factors studied for an association with GvHD and NRM were donor type (siblings/alternative donors), diagbnosis (CML others), year of DLI ( 2001), maximum dose of DLI ( 1×10^7), recipient age (40 years), donor age ( 40 years), number of DLI ( 4), interval transplant-DLI ( 282 days), phase of the disease at transplant (early/advanced), and gender (donor recipient). Results GvHD. Seventy patients (24%) developed acute GvHD grade II-IV. In univariate analysis we coujld only identify the year of transplant as a predictor: GvHD II-IV developed in 29% of patients grafted before 2001 and in 19% of patients grafted later (p=0.04). In multivariate analysis this result was confirmed. Results NRM. With a median follow up for surviving patients of 2346 days (125-7194) 158 patients survive (55%). The primary cause of death was relapse of the original disease in 100 patients (35%), whereas 29 died of NRM (10%). Factors predicting NRM in univariate analysis were interval diagnosis-DLI, donor type and patient age. In multivariate COX analysis, the strongest predictor for NRM was the interval between transplant and DLI (p=00001) with a RR of 6.6 of NMR for patients receiving DLI before the median intgerval (282 days). Other predictors were donor type (siblings had a risk of 0.43, p=0.04), patients age (with a risk of 2.3 for patients over the age of 40) and advanced disease at the time of transplant (p=0.01) Conclusions. In this relatively large series of consecutive DLI, the risk of acute GvHD was relatively low, and we could not identify significant predictors. NRM was strongly associated with the interval between transplant and DLI, and this may be a warning for strategies aimed at improving GvL in patients with advanced leukemia, with very early administration of DLI. Disclosures: No relevant conflicts of interest to declare.

Description: Background. Reactivation of Epstein Barr Virus (EBV) frequently occurs after allogeneic stem cell transplantation (ASCT) and EBV-induced lymphoproliferative disease is a potentially fatal complication. Aim of the study. Prevent EBV reactivation and EBV-induced post-transplant lymphoproliferative disease (LPD) after ASCT from alternative donors following anti-thymocyte globulin (ATG)-based conditioning regimen. Methods. In 2004, we initiated a pilot study with Rituximab given prophylactically on day +5 after an alternative donor transplant. We treated 68 patients with a fixed dose of 200 mg of Rituximab on day+5 and compared their outcome with a concurrent group of 77 controls who did not receive EBV prophylaxis. The two groups were comparable for patient and disease-associated variables, and all 145 patients received ATG as part of the conditioning regimen. Results. Rituximab on day +5 was well tolerated without any serious adverse event. Patients receiving rituximab had a significantly lower rate of EBV reactivation 41% vs 78% (p=0.0001), a lower number of EBV copies at reactivation (3 vs 10, p=0.04), a lower viral load expressed as maximum number of EBV copies (79 vs 1321,p=0.001) and a significantly lower proportion of patients with EBV copies exceeding 1000 (10% vs 44% p=0.001). Time to neutrophil and platelet engraftment was not different between the 2 groups. In the group treated with Rituximab, there was a trend for a lower incidence of acute GvHD grade II-IV (21 vs 34%, p=0.07) and grade III-IV (2 vs 8%,p=0.07), and for a reduced transplant related mortality (28 vs 39% p=0.1). Actuarial survival at 1-year was better for the Rituximab group (67 vs 50% p=0.09), but this did reach statistical significance. Conclusions. The use of Rituximab on day +5 after ASCT from alternative donors was safe and feasible. It did significantly lower the number of EBV copies at reactivation and the number of patients with an EBV load greater than 1000, at higher risk for EBV-related LPD. Thus, this approach may reduce the need of preemptive treatment or adoptive immunotherapy for EBV reactivation after an alternative donor transplant and may warrants further investigation.

Description: WHO classification and WPSS score (JCO2007;25:3503) have been recently proved to have prognostic significance in myelodysplastic syndromes (MDS), but their impact on the outcome of patients (pts) receiving allogeneic stem-cell transplantation (allo-SCT) is still to be clarified. We retrospectively evaluated the prognostic value of WHO classification and WPSS at the time of transplant in 406 MDS pts who underwent allo-SCT between 1990 and 2006. Patients were reclassified according to the WHO criteria: 30 had refractory anemia (RA/RARS), 54 refractory cytopenia (RCMD/RS), 51 RA with excess blasts (RAEB), type 1 and 95 RAEB type 2. One hundred twenty-seven pts were classified as acute myeloid leukemia (AML). The median recipient age was 48 years (range 17–67). There were 281 HLA-matched sibling and 125 unrelated donor SCT. One hundred forty-three pts (35%) received a reduced intensity regimen (RIC). Considering WHO categories, the probability of OS at 5-years was 0.8 in RA/RARS, 0.52 in RCMD/RS, 0.48 in RAEB-1, 0.26 in RAEB-2 and 0.29 in AML, while the probability of RFS at 5-years was 0.92, 0.78, 0.74, 0.47 and 0.44 respectively. The cumulative probability of TRM was 0.43. We performed a Cox analysis with WHO category, cytogenetics, transfusion dependency, recipient age, disease status, type of donor and type of conditioning as covariates. WHO classification had a significant effect on both OS (P=0.017), and RFS (P=0.01). Cytogenetic risk significantly affected RFS (P=0.04), while had a borderline effect on OS (P=0.09). A regular transfusion dependency before SCT was associated with a reduced OS (P=0.01) and increased TRM (P=0.037), while no significant effect on RFS was noticed. Age and stage of the disease at transplant showed a significant effect on OS (P=0.02 and P=0.04, respectively). RIC and active disease at transplant were associated to a reduced probability of RFS (P=0.02 and P=0.017 respectively). Age and use of myeloablative conditioning were significant risk factors for TRM (P=0.018 and P=0.032 respectively). The WPSS score, based on MDS-WHO category, cytogenetics and transfusion dependency at the time of SCT, was calculated for 171 pts. WPSS showed a prognostic significance on both OS and RFS in a Cox analysis with age of recipient, disease status, type of donor and type of conditioning as covariates (P=0.02 and P=0.01). Focusing the analysis on 84 MDS pts without excess blasts, multilineage dysplasia and regular transfusion-dependency significantly affected post-transplant OS (P=0.005 and P=0.009, respectively), and were associated to an increased TRM. In this clinical setting, WPSS allowed to identify 2 major groups of pts (very-low/low vs. intermediate risk) with significant different OS and TRM (P=0.013 and P=0.039). In conclusion, these data show that WHO classification and WPSS have a relevant prognostic value for the post-transplantation outcome of MDS pts and should be taken into account in transplantation decision-making, especially in subjects with less advanced disease. The independent negative effect of transfusion dependency strengthens the rationale to examine the consequences of iron overload and the potential benefit of chelation therapy in MDS transplant setting.

Description: Background Natural Killer (NK) cells have been widely studied due to their non-major histocompatibility complex (MHC)-restricted cytotoxicity towards transformed or virally infected target cells. In the setting of hematopoietic stem cell transplantation (HSCT), donor NK cells may be "alloreactive" as their killer immunoglobuline-like receptors (KIRs) do not recognize their ligands on recipient human leukocyte antigen (HLA) class I molecules (i.e. KIR-ligands), leading to NK activation. NK alloreactivity can often occur in haploidentical HSCT (Haplo-HSCT), by means of KIR/KIR-L mismatch in graft versus host (GvH) direction, contributing to graft-versus leukemia (GvL) effect, clearing residual leukemic blasts. In the last decade, several studies have shown that NK cells alloreactivity plays a role in T-depleted Haplo-HSCT leading to higher disease free survival rates for patients transplanted from NK-alloreactive donors; recent studies have also shown that donors having KIR B haplotypes (characterized by the presence of more activating KIR) or expressing KIR2DS1 correlated with a better clinical outcome of transplantation. Thus, these NK cell features might be positively considered in the donor selection strategy. Materials and Methods: We analyzed NK-alloreactivity in the setting of unmanipulated Haplo-HSCT with post-transplant cyclophosphamide for patients affected by acute myeloid leukemia or myelodisplastic syndromes. 101 consecutive patients transplanted from September, 2010 to October, 2014 were enrolled, with the big majority of donors and patients studied for HLA-genotype and KIR. Results: Disease status at HSCT was the most relevant factor affecting outcome (p =2) or who had KIR2DS1 was not associated with better outcome (p 0.67 and p 0.89, respectively). We observed an high expression of CD56 and inhibitory receptors such as NKG2A on surface of NK cells in post-HSCT samples, suggesting that NK-cell function could be inhibited in unmanipulated haploidentical setting. Conclusions NK alloreactivity seems not to play a role in preventing leukemia relapse in unmanipulated haploidentical transplantation with post-transplantation. The different immunosuppressive approach of this Haplo-HSCT setting compared to T-depleted Haplo-HSCT, with concomitant use of cyclosporine from early transplant days, which has been shown to interact and possibly inhibit NK cells in vivo, and post transplant cyclophosphamide effects, selectively killing activated T-cell and inducing long-term tolerance, could affect NK efficacy. Further studies are needed to better understand the complexity of this intriguing issue, leading to a more complete definition of NK cell functions in this Haplo-HSCT setting. Disclosures No relevant conflicts of interest to declare.

Description: Background. We have reported the use of two myeloablative regimens, for unmanipulated related haploidentical transplants (HAPLO) with post transplant cyclophosphamide (PT-CY) on 50 patients (BBMT 2013; 19: 117). Aim of the study. The aim of the present study is to update the outcome of our HAPLO program on 444 patients grafted between 2011 and 2017, in two transplant Units (Genova and Rome Gemelli). Patients. Patients were selected for HAPLO grafts in the absence of a suitable HLA matched related or unrelated donor. The median age of the patients was 52 years (14-74), and 106 patients were over 60 years of age. Remission status was as follows: CR1 (n=171), CR2 (n=112) and advanced disease (n=161). The median donor age was 34 years (18-67). The diagnosis was AML (n=154), ALL (n=87), MDS (n=83) , myelofibrosis (n=47), non Hodgkin lymphoma (n=31) other (n=44). Conditioning regimens: we used 2 myeloablative conditioning regimens , one chemotherapy based (n=346) including Thiotepa, Busulfan, Fudarabine (TBF) as described (BBMT 2013), and one radiation based (n=99) with full dose radiation (999-1200 rads) (TBI) and fludarabine (BBMT 2013). The TBF regimen was used with full dose Busulfan 3.2 mg/kgx3, or 3.2 mg/kg x2 , for patients over 60 years of age. The median age for the TBF regimen was 55 years (18-74), whereas for the TBI it was 35 years (14-64) . GvHD prophylaxis for all patients, was Cyclosporin (CsA) 2 mg/kg i.,v. starting day 0, mycophenolate 2 gr/day p.o, starting day+1 to day+30, PT-CY 50 mg/kg day +3 and day+5. When possible CsA was tapered starting day +100 and discontinued day +180. All patients received unmanipulated marrow as a stem cell source. Failure to engraft: the proportion of patients rejecting the graft was 0% for patients receiving TBI, 2.7% for TBF (BU3 days) and 6.7% for TBF (BU2 days ). Fourteen patients received a second HAPLO graft with the Baltimore regimen, and 11 achieved trilineage recovery . Death due to rejection was overall 0.75%. GvHD : The cumulative incidence of acute GvHD II-IV was 28% and of aGvHD grade III-IV 3%. The CI of moderate severe chronic GvHD was 18%. Cross section study 1 year post HAPLO. At one year post transplant 88% of patients were off CsA and 83% were off steroids .The average Karnofsky score was 97%. Chronic GvHD was scored as absent (68,7%) minimal (24.8%), moderate (4.8%) and severe (1.4%). Chimerism was scored as full chimera, in 96% of patients. Outcome. Non reapse mortality (NRM) at 4 years , was 16% for remission patients and 22% for patients with advanced disease (p=0.1). Relapse was 20%, 27%, 43% for patients in CR1, CR2, advanced disease (p

Description: Key Points Disease relapse is a common cause of failure of allogeneic hematopoietic stem cell transplantation in patients with advanced MDS. High IPSS-R prognostic risk category and monosomal karyotype are independent predictors of relapse after allogeneic transplantation in MDS.