ALBERT

Description: Clinical and molecular diagnosis of most hematological malignancies including Chronic Myeloid Leukemia (CML) can be accurately made. However, prediction of treatment response and estimation of disease survival period eludes the currently available tools for patient care. Quantitative expression proteomics can potentially be developed as effective tool to monitor therapy response towards achieving personalized medicine for CML patients. We have over 10 years follow up period for some of the CML patients, and the majorities of them are alive and doing well on Imatinib. On the other hand, a small fraction of the patients were switched to alternative Tyrosine Kinase Inhibitors (TKI) and some underwent bone marrow transplants (BMT). Our follow up results stratified all 37 analyzed newly diagnosed CP-CML patients into 5 distinct cohorts including 52% on Imatinib, 12% on Nilotinib, 9% on Dasatinib, and 15% BMT, while 12% of the patients had disease-related mortality. Kaplan-Meier survival curve showed no significant difference between all patients on TKI and BMT that were alive under a follow up period of 4-11 years compared. On the other hand 3 of 4 patients had disease related deaths less than 2 years of diagnosis. Only one patient survived for almost 10 years (Figure 1). Besides survival analysis, peripheral blood samples obtained from the patients at time of diagnosis were subjected to expression proteome analysis using label-free quantitative liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). A subset of significantly differentially expressed proteins was able to distinctively discriminate samples into their respective treatment response and disease outcome groups based on unique protein expression signatures (P 2- ∞- fold change, (Figure 2). Some of the identified proteins were implicated in hematological diseases including CML as potential biomarkers using Ingenuity Pathway Analysis. These protein signatures once validated in larger sample cohorts might be capable of prediction of molecular response, choice of therapy and disease outcome for CML patients. Therefore; allowing for identification of would be high risk patients that might potentially benefit from aggressive treatment at point of diagnosis pre initiation of conventional therapy. Altogether our findings indicate that analysis of panel of protein markers have the potential of clinical utility for prediction of response to therapy, disease survival and objective prognostication of disease outcome, thus bringing personalized medicine closer to CML patients. Disclosures No relevant conflicts of interest to declare.

Description: Introduction Predicting treatment outcome of acute leukemia has been an important issue. Many factors have been elucidated. We evaluated the impact of donor's availability on treatment outcome including mortality in patients with acute lymphoblastic leukemia (ALL). Methods A total of 294 patients with ALL were evaluated after receiving chemotherapy between year 2001 and July 2014 at our center. Patients were assessed for the need of hematopoietic stem cell transplants (HSCT), availability of HLA sibling match donor and the impact on overall outcome. Indications for transplantation were defined as (1) WBC-〉100,000 for T-ALL, 〉30 for B-ALL with, (2) cytogenetic abnormalities of t(9:22), (4:11) or (1:19), (3) relapse or primary refractory disease or (4) MRD positivity. Patients were divided into 3 categories, group A with an indication for HSCT and available donor (HSCT+/D+), group B with HSCT indication but no available donor (HSCT+/D-) and group C with no indication for HSCT regardless of donor status (HSCT-). Results The median age was 20 (14-63 years). 95 (32%) were female while 198 (68%) were male. 276 (86%) patients were newly diagnosed while 18 (14%) were relapsed. Immuno-phenotype was B for 191 (65%), T for 91 (31%) versus mixed lineage for 12 (4%). 33 (11%) patients were positive for Philadelphia chromosome. Median WBC at diagnosis was 23.2X109/L CNS involvement was positive in 26 (8%) patients. With a median follow-up of 60 months for survivors (range 2 to 116.5 months), 148 (50%) patients showed HSCT+/D+, HSCT+/D- in 79 (27%) and HSCT- in 67 (23%) patients. the 5-year OS for HSCT+/D-, HSCT+/D+ and HSCT- were 29%, 57% and 55% (p value

Description: A Significant Proportion of Young Adult Patients with Post -HCT Relapse Of AML Benefit From Aggressive Salvage And 2nd Cellular Therapy. INTRODUCTION: There is currently no standard of care for patients with AML who relapse following hematopoietic cell transplantation (HCT), and outcomes in these patients are generally poor. Given this fact, there is great variability in practice, and many patients may be palliated in the absence of suitable clinical trials, especially following early relapses. We sought to analyse long-term survival of young adults with AML based on whether or not they received a second cellular therapy (CT) (second transplant or donor lymphocyte infusion [DLI]) following post-HCT relapse. METHODS: We retrospectively analysed data on patients who had received a HCT between 2000 and 2012 and had a post HCT relapse. The patients were stratified by whether or not they had 2nd CT with or without prior chemotherapy. Baseline characteristics and outcomes were compared. RESULTS: Ninety four patients were identified who had relapsed AML following HCT. The median age at transplant for the patients was 27.5 (range 14-58y) years for the whole cohort; 50% were females. Of these, 30 patients received 2nd CT either in the form of DLI (80% for available CT data) or a 2nd HCT. Median in age for both groups was 24 years and there was no significant difference between the 2 groups in good or poor risk cytogenetics. Median time to relapse was significantly lower in the group that did not receive 2nd CT vs the group that did (5.9 vs 18.2 months, p

Description: Introduction: Despite allogeneic hematopoietic stem cell transplantation (HSCT), prognosis of fms-like tyrosine kinase 3 (FLT3) mutated acute myeloid leukemia (AML) remains poor due to the high risk of relapse. Sorafenib, a multikinase inhibitor active on FLT3, has shown encouraging results in these patients. Patients and methods: Here, we report the use of sorafenib as a maintenance agent after HSCT in 28 adults with FLT3 positive AML treated in three hematologic departments. Results: A total of 18 males and 10 females were included. All but one patient (pt) underwent their first HSCT between 2012-2016. Median age at HSCT was 45 years (range 16-57). A normal karyotype was detected in all but 5 pts. Ten pts showed FLT3-ITD as sole molecular abnormality, thirteen with concomitant NPM-1 mutation, associated to WT1 overexpression in 1 case and to CEBP-α double mutated in two. Association of FLT3 and WT1 overexpression was observed in 3 pts. Two more pts presented a FLT3-TKD with concomitant NPM-1 mutation. At time of HSCT, all but 1 pt were in complete remission (CR; CR1, n=23; CR2=3; CR3=1). Thirteen pts in CR had a detectable minimal residual disease (MRD) before HSCT. Median interval from CR to HSCT was 74 days (d, range 6-220). The majority of the pts (n=26) received peripheral blood as stem cell source, 19 from a matched sibling, 4 from a matched unrelated, 3 from a haploidentical donor. A bone marrow unit was used in 2 pts, one matched sibling and one haploidentical donor. Conditioning regimen was myeloablative in 21 pts, while reduced intensity regimen was used in 5 pts, and 2 receiving a sequential regimen. All pts achieved neutrophil engraftment in a median of 16 d. Median time to sorafenib introduction as a maintenance agent after HSCT was 70 d (range 17-645). Seven pts were out of immunosuppressive treatment (IST) without graft-versus host disease (GVHD) at time of sorafenib start. Sorafenib was started at a dose of 400 mg twice a d (n=13), 200 mg twice a d (n=14) or 200 mg once a d (n=1). Sorafenib was used as primary prophylaxis in 25 pts, or as secondary prophylaxis in three relapsed pts who received it first in combination with salvage chemotherapy and then, after obtaining subsequent CR, as a maintenance treatment. Median duration of treatment was 179 d (range 4-1219). Dose reduction or withdrawal due to toxicities was needed in 5 and 3 pts, respectively. These included gastrointestinal (GI, n=3), cardiac (n=1), skin (n=3, 1 with GI), biochemical (n=1) and hematological toxicities (n=2, 1 with GI). Despite dose reduction, persistence of toxicities prompted to treatment withdrawal in 1 pt. Disease relapse occurred in 2 pts: in both sorafenib was withdrawn and then resumed after salvage chemotherapy. One pt died for disease progression, the other from non-relapse mortality. Twelve pts experienced GVHD (limited, n=6; extensive, n=6), resulting in dose reduction in 5 pts, followed by withdrawal in 1 pt. Nine pts required systemic IST. Dose reduction was made in 1 pt due to financial reasons. Three pts received donor lymphocyte infusion (DLI), without experiencing GVHD. Leukemia-free (LFS) and overall survival at one year were 91±6% and 89±7%, respectively. Probability of LFS with undetectable MRD at one year was 87±7%. With a median follow-up of 15 months (range 4-44), all but 2 pts are alive, all in CR. Sorafenib treatment is ongoing in 18 pts (with 7 at reduced doses) with a median of 15 months (range 1-41). Conclusion: Our findings suggest that a post-transplant prophylactic strategy is safe and may markedly improve the poor outcome of FLT3 positive AML. A large prospective randomized clinical trial is warranted in order to confirm our results and to determine the optimal treatment modalities. Although the optimal starting dose still remains unclear, dose individualization according to patient tolerability might be considered. Further analysis is needed to evaluate the immunomodulating role of sorafenib post HSCT. Figure 1 year Leukemia-free and overall survival Figure. 1 year Leukemia-free and overall survival Disclosures No relevant conflicts of interest to declare.

Description: Introduction: It is extremely significant to predict treatment outcomes using a biomarker. The prognostic significance of CD20 expression is controversial. In this study, we attempted to evaluate the impact of CD 20 expression on treatment outcomes in large cohort of adolescents and adults patients with acute lymphoblastic leukemia (ALL) treated with chemotherapy only in one single center. Methods: A total of 172 adolescent and adult patients with newly diagnosed B precursor ALL receiving CALGB based chemotherapy protocol between year 2001 and July 2014 at our Centre were evaluated for the expression of CD20 and it is impact on treatment outcomes. Anti-CD20 monoclonal antibody use were not part of the chemotherapy protocol at our Centre. Patients underwent hematopoietic stem cell transplantation were excluded from the analysis, a total of 83 patients were finally included in the analysis. CD20 expression at diagnosis of 20% in blast population was used as cutoff to stratify patients as CD20 positive (CD20+) versus CD20 negative (CD20-) group. Results: Median age for all patients is 21 years (range, 14-62), 41% (n=34) were females. Median WBC at diagnosis was 8 (range, 0.4-244), 28% (n=23) had WBC 〉30. Philadelphia (Ph) chromosome was negative for 75 patients (86%) while positive for 12 patients (14%). Day 28 blasts 5 (n=5) and missing for 4 patients (5%). A median follow-up of 3.7 years for survivors (range, 1-11) showed 29 patients (35%) had CD20+ versus 54 patients (65%) was CD20-. Comparison of patient's characteristics between the two groups were similar for gender, age, median WBC at diagnosis, median LDH, Ph chromosome, CNS involvement and primary refractoriness at day 28 of chemotherapy. The cumulative incidence of relapse at 1 year for CD20+ was 42% versus 15% (p=0.05) for + CD20- (Figure 1) while 5 years relapse rate was 55% versus 58%, respectively, suggesting higher incidence of 1 year relapse in CD20+ group. The overall survival for CD20+ was 39% versus 50% for CD20- (P=0.18). In Univariate analysis for One-year relapse, CD20 expression was significant factor (p=0.02, HR=2.97). Multivariate analysis confirmed CD20 as an independent adverse risk factor for relapse at 1 year (p=0.02, HR 2.97). For 5-years relapse, male gender (p=0.03, HR 2.1) and age 〉30 years (p=0.05, HR2.38) were found to be independent factors but not CD20 expression. Conclusion: The present study showed that the overall incidence of CD20 expression in B-ALL is 35%. Also, it suggested that in non-HSCT patients, CD20 expression at a diagnosis is associated with higher risk of early relapse at one year, which was confirmed by multivariate analysis. Further study is strongly warranted to confirm the prognostic role of CD20 and to evaluate the importance of anti-CD20 monoclonal antibodies in a prospectively designed study. Figure 1. Cumulative incidence of relapse at 1 year (A) and at 5 years (B) Figure 1. Cumulative incidence of relapse at 1 year (A) and at 5 years (B) Figure 2. Figure 2. Figure 3. Figure 3. Disclosures Kim: Bristol-Myers Squibb: Consultancy, Research Funding; Novartis Pharmaceuticals: Consultancy, Research Funding.

Description: Introduction: Various forms of aplastic anemia (AA)/bone marrow failure syndromes (IBMFs) show significant clinical and molecular heterogeneity with significant clinical overlap and are often diagnosed based on established clinical and pathological criteria. While 〉70 genes have been identified in patients with AA/IBMFs, most cases have are labelled as idiopathic with no identifiable genetic abnormlaity found. Precise detection of genetic abnormalities in these patients may assist in more accurate molecular diagnosis in these patients, proper counseling, cancer surveillance and personalized clinical intervention. Method: As part of the Saudi Human Genome Project, we developed a comprehensive 405 gene panel encompassing all known Mendelian hematological disorders (hemolytic anemias, aplastic anemias/bone marrow failure syndromes, coagulation disorders) using the Ion Torrent AmpliSeq technology. Patients who met the clinical diagnosis of aplastic anemia/bone marrow failure syndrome were enrolled into this study. Peripheral blood samples were subjected to this next-generation sequencing analysis. Results: We validated the Saudi Mendeliome assay using 642 samples with known mutations across various medical specialties. We then tested 37 patients with AA/IBMFS using this Proton-Ion sequencing platform. Mutations were identified in 7/37 (19%) of patients, followed by whole exome sequencing (WES) in those patients without identifiable mutations. Conclusion: Compared with clinical WES and/or whole genome sequencing (WGS), which are still expensive, time consuming and difficult to interpret, this novel and comprehensive targeted gene panel is more economical (〈 $150), faster (3-4 weeks), upgradable (by spiking in newly identified AA/IBMFs genes) and can be used to genotype patients with acquired aplastic anemia/bone marrow failure syndromes and guide their management. Second tier testing using WES/WGS is recommended for cases without identifiable mutations. Disclosures No relevant conflicts of interest to declare.

Description: Introduction:Acute kidney injury (AKI) and chronic kidney disease (CKD) affect 10-70% of transplant recipients. Onset of kidney injury varies from days to months or years after transplantation. Kidney injury may be caused by multiple factors. Long-term data on cyclosporine induced nephrotoxicity post HSCT are limited. It is unclear if cyclosporine induced nephrotoxicity at early phase post HSCT will impact long term renal function. The objective of this study is to evaluate the progression of renal function in allogeneic hematopoietic stem cell transplant (HSCT) patients, before, during and after cyclosporine therapy. Methods:This is a retrospective single arm cohort study evaluating the impact of cyclosporine on renal function in patients who underwent allogeneic HSCT from 2003 through 2013. Patients age≥ 14 years who underwent allogeneic HSCT and received cyclosporine as graft-versus-host disease (GVHD) prophylaxis and alive two years post HSCT without disease relapse or GVHD were included in the study. Primary outcome was the change in serum creatinine and estimated creatinine clearance. Delta creatinine (baseline creatinine - creatinine on day 25, day 100, day 180, year 1 and year 2 post HSCT) was used to calculate the change in the serum creatinine and estimated creatinine clearance. Estimated creatinine clearance was calculated using Cockcroft and Gault formula (CG) for patients aged ≥ 18 years. Schwartz formula was used to estimate creatinine clearance for patients aged ≥ 14 years till 18 years. The secondary outcome was the incidence of acute kidney injury. AKI was defined as per RIFLE criteria. The severity grades were defined on the basis of the changes in serum creatinine. CKD was defined if estimated glomerular filtration rate (GFR)

Description: Introduction: Induction with 3+7 has been standard practice in acute myeloid leukemia (AML) for over 40 years. Addition of a 3rd agent or use of high dose Ara-C has been reported to show better CR rates, but this has not demonstrated a consistent improvement in overall survival. We have consistently used induction with idarubicin, cytarabine 100mg/m2 /day for 7 days and etoposide at 100mg/m2 in young patients, omitting etoposide for suspected secondary AML or AML with myelodysplasia related features, or in those in whom excess toxicity is suspected. Methods: All patients wholly treated for newly diagnosed AML were identified from the prospective institutional AML database. Patients were treated with either ICE (Idarubicin 12mg/m2 day 1-3, Ara-C 100mg/m2 day 1-7, Etoposide 100mg/m2 d1-3) or the same doses of idarubicin and Ara-C without etoposide (3+7). The latter was given in patients with dysplastic features or secondary AML or where there were concerns of toxicity. Results: We Identified 116 patients who received one of the 2 induction regimen between 2005 and 2013. 90 patients received ICE and 26 patients received 3+7. Median ages in the groups were 29y (14-56) and 37y (15-58), respectively. Cytogenetics by ELN classification were similarly distributed between the ICE and 3+7 groups, with favourable/intermediate/adverse cytogenetics comprising 22%/46%/26% and 23% / 38% / 26%, respectively. 21/90 (23%) in the ICE group had 〉5% blasts in a day 14 bone marrow vs 7/26 (27%) in the 3+7 cohort. There was no significant difference in the CR/CRi rate between ICE (82%) and 3 + 7 (77%) groups. The death in aplasia rate was similar at 3.3% and 3.8%, respectively. 65/90 (72%) and 14/26 (54%) of patients received a transplant in CR1 or beyond in the ICE and 3+7 groups, respectively. Leukemia free survival was 40% (SE 10%) and 40% (SE 5%) in both cohorts (Fig.1). Overall survival at 5 years for ICE and 3+7 were 57% (SE 6%) and 49 % (SE 13%), p=0.69 (Fig.2). Conclusion: Our experience in young adults, albeit retrospective, confirms findings of larger studies that demonstrate that addition of etoposide to induction does not appear to improve remission rates significantly or improve survival. In order to improve remission rates in younger adults, FLAG-Ida or other regimens consisting of high dose Ara-C and/or novel agents may provide more tangible improvements in remission rates, although strategies that translate these into better overall survival remain elusive and this should be the target of further prospective trials. Disclosures No relevant conflicts of interest to declare.

Description: Background/Purpose: Bone marrow failure syndrome is an example of disease entity where accurate diagnosis of Severe Aplastic Anemia (SAA), Paroxysmal Nocturnal Hemoglobinuria (PNH) and Hypoplastic Myelodysplastic Syndrome (MDS) is very challenging. The aim of this study was to identify panels of disease-specific /disease-associated proteins biomarkers to be used for more objective diagnosis and better prediction of disease prognosis of patients presenting with features of bone marrow failure syndromes. Methodology: Bone marrow plasma (MBP) and peripheral blood plasma (PBP) samples from 20 patients with bone marrow hypoplasia; including AA/MDS/PNH were subjected to expression proteome analysis using label-free quantitative liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). Results: Approximately 300 unique protein species were identified of which 107 and 218 were significantly differentially expressed (〉 2- ∞- fold change & p 〈 0.05) in BMP and PBP respectively. These protein fingerprints independently discriminates patients into three distinct clusters; AA/MDS/PNH. Furthermore, only approx. 25% of the proteins were common between the two datasets from BMP and PBP. Some of the identified proteins were filtered and mapped using Ingenuity Pathway Analysis, and were associated with five different networks. The top two of these networks involved cell-to-cell signaling interaction, hematological system development and function, and immune cell trafficking. Only three of the differentially expressed proteins were uniquely expressed in SAA and MDS but absent in PNH, thus making these proteins potential biomarkers. The probable diagnostic utility of these proteins would be validated in large archival clinical samples. Our data indicates the utility of multivariate analysis of quantitative proteome data as a means of discovery of disease related or disease specific biomarkers for bone marrow syndromes. Conclusions: We have identified protein signatures capable of objective classification of bone marrow failure syndromes patients. Our expression proteomics strategy is very promising for identification of clinically useful biomarkers. These proteins once validated, on a larger cohort of patients, might be valuable to complement the currently existing parameters for reliable and objective disease diagnosis, monitoring treatment response and clinical outcome of bone marrow failure syndrome patients. Disclosures Owaidah: King abdulaziz city for science, Novo Nordisk, Bayer: Honoraria, Research Funding.

Description: Introduction : Infertility is a major late effect of hematopoietic stem cell transplants (HSCT). In aplastic anemia (AA) patients, although the fertility recovery rate is relatively higher than other diseases but the exact incidence and risk factors are not very well studied. In this study, we attempted to evaluate incidence and the impact of patientÕs characteristics and transplantation procedures on fertility recovery following allogeneic HSCT for adolescent and adults patients with AA. Methods : A total of 157 patients who were at least 14 years old with AA receiving HSCT between year 1987 and 2014 at our center were reviewed. Patients who survived at least 2 years following HSCT and either married or in relationship were included in the analysis and evaluated for fertility following HSCT. 87 patients were eligible for the study. Questionnaire survey and long-term charts were used for data collection. With a response rate and or available information of 63% patients, 55 patients were identified and stratified into fertility recovery (FR+) versus non-fertility recovery (FR-) group. Fertility recovery was defined by a pregnancy of the patient or his partner. Results: Median age for all patients is 23 years (range, 14 -50), 44% (n=24) between 14-20 years old, 51% (n=28) between age 20-40 years and 5% (n=3) 〉 40 years. 51% (n=28) were females. Matched related donor was used for majority of patients 96% (n=53). GVHD prophylaxis was CSA/MTX for 93% (n=51,). Conditioning regimen was Cyclophosphamide/Flu in 25 (45%), Cyclophosphamide /ATG in 18 patients (35%) and others in 12 patients (20%). Bone marrow was the source of stem cells for 52 patients (94%). A median follow-up of 8 years for survivors (range, 0.3 -23) showed 45 patients (82%) had FR+ while 10 patients (18%) were FR-. Median duration of fertility recovery (from delivery to BMT) was 6 years (range, 0.8-19) with significant difference based on age groups, 4 years for patients 20-40 years (n=29, 53%) versus 8 years for those 〈 20 years (n=24, 44%), (p=0.002), (Figure 1). None of the patients 〉40 years old (n=2, 4%) had fertility recovery. Comparison based on gender showed no significant difference. Males had a median duration of fertility recovery of 5.9 years, (range 0.6-14.9) versus 6.2 years, (range, 0.8-15.2) (p=0.31) females. The overall median number of pregnancies was 2 (range, 1-6). For males, it was 2 (range, 1-6) while 1.5 (range, 1-5) for females (p=0.26). Deliveries occurred in natural ways in (95%) while C-section for (5%). All deliveries were without fetal abnormalities. Univariate analysis of risk factors for fertility recovery showed age group (p=0.03) and chronic GVHD (p=0.05) are important factors. Neither gender of patients or type of preparative regimens used for HSCT (Cyclo/ATG vs Cyclo/Flu) was a risk factor. In multivariate analysis, age group was the only confirmed an independent risk factor for fertility recovery (p=0.02) [HR= 2.02, CI=1.012-3.64). Conclusion: The present study suggested that the incidence of fertility recovery following HSCT for patients with aplastic anemia is high with no significant differences between males and females. Patients between the ages of 20-40 years at the time of HSCT have significantly shorter recovery period. Age was the only independent risk factor for fertility recovery while there was no impact of whether ATG or Fludarabine was used in addition to Cyclophosphamide as preparative regimen. Figure 1. Figure 1. Disclosures Kim: Bristol-Myers Squibb: Consultancy, Research Funding; Novartis Pharmaceuticals: Consultancy, Research Funding.