ALBERT

Description: BACKGROUND: Venetoclax is an effective oral agent for frontline treatment of patients with chronic lymphocytic leukemia (CLL). Due to the rapid induction of cell death caused by the targeted activity of venetoclax, some patients require inpatient monitoring for tumor lysis syndrome (TLS) at initiation of therapy. In the recent CLL14 study, 64% and 22% of venetoclax-treated patients were medium and high risk for TLS, respectively. This study used disease re-staging every two cycles to explore the efficacy of using of obinutuzumab, with or without bendamustine prior to initiation of venetoclax, to reduce tumor burden and thus eliminate the need for hospitalizations, as well as reduce the risk for TLS at the initiation of venetoclax therapy. METHODS: This is a single arm open-label, phase 3b trial (NCT03406156). Patients had previously untreated CLL/SLL (excluding those with 17p deletion), an Eastern Cooperative Oncology Group (ECOG) performance score of ≤1, and a medium (any lymph node 5 -

Description: Key Points The outpatient BV and bendamustine regimen is highly active as first salvage therapy in relapsed/refractory HL, with manageable toxicity. The CR rate of 73.6% exceeded those reported for standard chemotherapy regimens, and post-ASCT outcomes generally appeared excellent.

Description: Background Long-term outcomes from autologous stem cell transplant (ASCT) in patients (pts) with relapsed/refractory (R/R) Hodgkin lymphoma (HL) are significantly better in patients who achieve a complete remission (CR) from salvage chemotherapy prior to ASCT. However, standard salvage therapy produces variable CR rates (19%-60%) and is associated with significant toxicity. Brentuximab vedotin and bendamustine are highly active when administered as single agents to pts with R/R HL (34% and 33% CR rates, respectively) and have manageable safety profiles. This phase 1/2, single-arm, 2-stage, open-label study was designed to evaluate the safety and efficacy of brentuximab vedotin in combination with bendamustine for the treatment of pts with primary refractory disease or in first relapse (ClinicalTrials.gov #NCT01874054). Methods Pts received an outpatient IV infusion of 1.8 mg/kg brentuximab vedotin on Day 1 with bendamustine on Days 1 and 2 of 3-week cycles for up to 6 cycles. Pts could undergo ASCT any time after Cycle 2 and post-transplant resume treatment with brentuximab vedotin as monotherapy for up to 16 total doses. Phase 1 was designed to determine the recommended dose of bendamustine, with an initial dose of 90 mg/m2 and a de-escalation scheme to be implemented if it exceeded the maximum tolerated dose. During phase 2, bendamustine was administered at the recommended dose in order to assess the CR rate of the combination. Response was assessed by the investigator per Cheson 2007. Enrollment is complete and long-term follow-up for PFS and OS continues. Results Fifty-five pts (56% female) with a median age of 36 yrs (range, 19-79) were enrolled. Fifty-one percent of pts had relapsed disease and 49% of pts had primary refractory disease after frontline therapy. A median of 13.8 mos (range, 3-98) had elapsed since initial diagnosis. No dose-limiting toxicities were observed in the safety cohort, thus the recommended dose of bendamustine in combination with brentuximab vedotin was 90 mg/m2. Pts received a median of 2 cycles (range, 1-6) of the combination and a median of 9 cycles (range, 1-14) of single-agent brentuximab vedotin. The main toxicity observed with the combination was infusion-related reactions (56% overall). The most common symptoms (≥10%) were pyrexia (26%), chills (20%), dyspnea and nausea (15% each), flushing (13%), and hypotension (11%). Premedication with corticosteroids and antihistamines was instituted with a protocol amendment and appeared effective. Before the amendment, 6 pts (24% of treated pts) discontinued treatment prematurely because of IRRs; post-amendment, IRRs led to treatment discontinuation for 2 pts (7%). The CR rate of the combination was 74% (39/53 pts evaluable for response) and the overall objective response rate (CR and partial remission) was 93% (49/53 pts). The CR rate was 64% and 84% for refractory and relapsed pts, respectively. Stem cell collection after first-line mobilization (G-CSF± plerixafor) was successful in 93% of pts (37/40). Median number of CD34+ cells collected was 4.1 x106 (Q1, Q3: 3.0, 5.4) in a median of 2 (range, 1-5) apheresis sessions. Median time to neutrophil and platelet engraftment was 11 days (range, 9-21) and 13 days (range, 9-39), respectively. Pts have been followed for a median of approximately 1 year from first dose (median = 418 days; range, 118-635) and approximately 10 mos (314 days; range, 13-553) from ASCT. To date, 12 progression events have been observed: 7 in the 40 pts who underwent transplant and 5 in the 13 pts who did not undergo transplant. The estimated 12-mos PFS is 80% for both the transplanted population (95% CI: 70%, 90%) and the overall population (95% CI: 60%, 90%). Three of the 12 progression events were deaths; 2 pts died from progression of their HL and 1 pt died from septic shock after transplant. Conclusions The outpatient regimen of brentuximab vedotin 1.8 mg/kg on Day 1 in combination with bendamustine 90 mg/m2 on Days 1 and 2 of 3-week cycles induced a very high CR rate that compares favorably with historical data. The regimen has a manageable safety profile, with the most significant side effect being IRRs that can be successfully managed by premedication. The estimated 12-mos PFS rate of 80% demonstrates response durability, making the combination a promising salvage regimen for pts with HL in the first relapse setting. Progression-Free Survival Figure 1. Figure 1. Disclosures Off Label Use: Brentuximab vedotin is indicated in the US for treatment of patients with Hodgkin lymphoma after failure of autologous stem cell transplant or after failure of at least two prior multi-agent chemotherapy regimens in patients who are not ASCT candidates and for the treatment of patients with systemic anaplastic large cell lymphoma after failure of at least one prior multi-agent chemotherapy regimen. This study evaluates brentuximab vedotin in HL patients with primary refractory disease or in first relapse. . Sawas:Seattle Genetics, Inc.: Research Funding. Agura:Seattle Genetics, Inc.: Research Funding. Matous:Takeda Pharmaceuticals International Co.: Speakers Bureau; Celgene: Consultancy, Speakers Bureau; Seattle Genetics, Inc.: Research Funding, Speakers Bureau. Ansell:Bristol-Myers Squibb: Research Funding; Celldex: Research Funding. Crosswell:KIYATEC (employment); Gilead (common stock ownership and research funding): Employment, Equity Ownership, Research Funding. Islas-Ohlmayer:Seattle Genetics, Inc.: Research Funding. Behler:Seattle Genetics, Inc.: Research Funding; Onyx Pharmaceuticals: Speakers Bureau. Cheung:Seattle Genetics, Inc.: Research Funding. Forero-Torres:Seattle Genetics, Inc.: Research Funding. Vose:Seattle Genetics, Inc.: Honoraria, Research Funding. Josephson:Seattle Genetics, Inc.: Employment, Equity Ownership. Advani:Seattle Genetics, Inc.: Research Funding; Genetech: Consultancy.

Description: Abstract 2277 Poster Board II-254 Background: Plerixafor plus G-CSF has been shown to mobilize more CD34+ cells than G-CSF alone for autologous (auto) hematopoietic stem cell transplant (HSCT). However, many centers use chemotherapy followed by G-CSF to mobilize CD34+ cells prior to HSCT. Comparing the effectiveness of CD34+ cell mobilization, cost, logistical issues, and clinical outcomes between plerixafor/G-CSF and chemotherapy/G-CSF mobilized pts may help better define optimal mobilization regimens. Patients and Methods: We performed a retrospective study of pts who participated in the expanded access program (EAP) of plerixafor/G-CSF for upfront mobilization of CD34+ cells, and compared the costs of mobilization and clinical outcomes to matched historical controls mobilized with chemotherapy/G-CSF at two centers that participated in the study. Control pts were matched for age, sex, disease stage, and number of prior therapies. Control pts received cyclophosphamide 3-5 gm/m2 followed by daily G-CSF. Study pts received G-CSF 10 mcg/kg daily for 5 days and plerixafor 0.24 mg/kg was given on the evening of day 4, twelve hours before a 3 blood volume apheresis on day 5, and the same plerixafor and G-CSF dosing was given for each subsequent day of apheresis. Apheresis was scheduled for 5 days after starting G-CSF in the study pts and 10 days after starting G-CSF in the control pts, but the actual start of apheresis was based on the peripheral blood (PB) CD34+ cell counts of 10/ul or greater. Mobilization costs were considered to be the costs of medical procedures, resource utilization and medications. Median national CMS national reimbursement rates were used to evaluate the costs of mobilization procedures, hospitalization, provider visits, apheresis, CD34+ cell processing and cryopreservation. Average sale price was used for medications related to mobilization including G-CSF, plerixafor, cyclophosphamide, mesna, antiemetics and antimicrobials. Results: A total of 34 patients from EAP and 34 matched controls were studied (Rocky Mountain BMT:25 study pts and 25 controls, Texas Transplant Institute:9 study pts and 9 controls). Study pts had a median age of 58 years, 18 (53%) were male, and had myeloma (n=20, 59%), or NHL (n=14, 41%). Control pts had a median age of 58 years, 18 (53%) were male and had myeloma (n=20, 59%), NHL (n=13, 38%), or Hodgkins disease (n=1, 3%). Comparison of the G-CSF dose, the number of doses of G-CSF, number of apheresis, total CD34+ cells collected, and cost is given in the table. All pts proceeded to auto HSCT with no difference in median time to ANC or platelet engraftment. The median costs of mobilization were similar between the groups. Two pts in the control group were hospitalized for neutropenic fever during the mobilization period after receiving cyclophosphamide. Apheresis started on the scheduled day in 27 (79%) of study pts and in 18 (53%) of control pts (p=0.021). Unplanned starts of apheresis resulted in 17 (50%) of control pts undergoing weekend apheresis. CMS national reimbursement data does not differentiate the costs of weekend or weekday apheresis or flow cytometry, and thus no cost difference for weekend procedures is reflected in the cost data. Study pts received a median of 1 dose of plerixafor (median 16.9 mg), and the average sale price for plerixafor in this analysis was set at $6,250 per 24 mg/vial. Adding this cost to the study pts resulted in a non-significant difference in total cost of mobilization for the two groups. Conclusion: In conclusion, plerixafor/G-CSF compared to cyclophosphamide/G-CSF for upfront mobilization of CD34+ cells for auto HSCT results in similar number of cells collected, cost of mobilization, and clinical outcomes. However, plerixafor/G-CSF mobilization resulted in more predictable days of collection, no weekend apheresis procedures, and no unscheduled hospital admissions. Higher acquisition cost of plerixafor was offset by less G-CSF use and less resource utilization compared to cyclophosphamide based mobilization. Disclosures: Shaughnessy: Genzyme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Silva:Genzyme: Consultancy. Steinberg:Genzyme: Consultancy. Selvey:Genzyme: Consultancy. Maris:Genzyme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. McSweeney:Genzyme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Description: Introduction:Thrombocytopenia is a common problem in hospitalized patients, which has a diverse etiology. One of the infrequent causes is heparin-induced thrombocytopenia (HIT), a complex immune disorder in which heparin leads to the production of IgG antibodies, targeting platelet factor 4 (PF4). HIT diagnosis is based on a decrease in the platelet count of more than 50% beginning 5 to 10 days after starting heparin, in association with platelet-activating HIT antibodies (screening test), positive functional tests (confirmatory tests), in patients with no alternative causes for thrombocytopenia, necrosis or thrombosis (Figure 1). Most patients admitted to our institution receive unfractionated or low molecular weight heparin for venous thromboembolism prophylaxis. The risk of HIT depends on the type of heparin the patient receives. Even though HIT is rare, we tend to have a high suspicion and low threshold to order laboratory workup for this condition, occasionally without using the 4T«s score (Table 1). The 4T«s score is a validated system with a very high negative predictive value (NPV) of up to 99%, when the score is ²3. The aim of this study is to determine if the 4T«s score has been used appropriately in our institution. It is a very useful tool with a high negative likelihood ratio and using it systematically may decrease unnecessary laboratory testing, consequently decreasing costs and potentially length of stay. Methods:This is a retrospective descriptive study from a single teaching community hospital. Between January and December of 2015, 57 HIT screening tests (PF4 ELISA) were ordered in our institution. We reviewed all of the patient charts to determine their 4T«s score. The patients were divided into low, moderate and high pretest probability based on their score (low probability if ²3, intermediate 4-5, and high if ³6). The data analysis was completed with SPSS software. Results:57 tests were ordered, 5 patient charts did not have enough information to calculate 4T«s score and were excluded. 52 charts were reviewed, 28 patients were male and 24 were female (53 and 46% respectively), and they were between 25 and 89 years of age. 7 (13.4%) did not receive heparin (during current hospitalization or within 100 days), 11 (21.1%) received therapeutic doses of unfractionated heparin, 11 (21.1%) received prophylactic doses of unfractionated heparin, and 23 (44.2%) received prophylactic low molecular weight heparin (enoxaparin). The 4T«s score was calculated for each patient; 40 were low risk, 10 intermediate risk and 2 high risk (76.9, 19.2, 3.8% respectively). All the patients had HIT screening antibodies ordered; only 10 (19.2%) were positive and from those only 1 (1.9%) was confirmed by the serotonin release assay. This confirmed patient had a 4T«s score of 6. Of the 7 tested patients who did not receive heparin, none had a positive screening test (all had 4T«s score of 1 or 2). 35 of the screening tests were ordered by internal medicine residents, 5 by surgical residents, 12 by attending physicians (67.3, 9.6 and 23% respectively). Previous studies validated that a 4T«s score of ²3 can predict negative results for the confirmatory tests. By using theMcNemar«stest for matched pairs, we attempted to determine a cut off for the 4T«s score that would predict a negativeHIT screeningtest. We found that a 4T«s score ²2 predicted a negativeHIT screeningtest, with aNPVof 75% (p=0.0018). Since our study included a small patient cohort and due to the possibility of laboratory work up not being ordered in patients with a low 4T«s score, we suspect theNPVis actually lower than our current finding. A prospective study with a larger cohort of patients would be necessary to confirm these findings. Conclusions:Only 12% of the patients had a 4T«s score ³4 that would warrant laboratory work up, therefore we concluded that PF4 ELISA screening tests have been over utilized in our institution, increasing false positive results, length of stay and cost of hospitalization in patients without a significant risk for HIT. This could be avoided by calculating the 4T«s score before obtaining any further laboratory tests. The 4T«s scoring system has been validated by multiple studies with large cohorts in the past. We will continue to work with our staff, especially the residents, to improve education on HIT and adequate diagnosis, based on current guidelines. Disclosures No relevant conflicts of interest to declare.

Description: Background Patients (pts) with Hodgkin lymphoma (HL) who have relapsed/refractory disease after frontline therapy typically undergo salvage chemotherapy followed by high-dose conditioning and autologous stem cell transplant (ASCT). Improved outcomes have been reported for pts who achieve complete remission (CR) with salvage chemotherapy prior to ASCT. Variable CR rates (19%-60%) and significant toxicities are associated with standard salvage therapy in the first relapse setting. Brentuximab vedotin and bendamustine have independent mechanisms of action and are highly active with manageable safety profiles when administered as single agents to pts with HL who relapse after ASCT (brentuximab vedotin: 34% CR [Younes, 2012]; bendamustine: 33% CR [Moskowitz, 2013]). This phase 1/2, single-arm, 2-stage, open-label study was designed to evaluate the safety and efficacy of brentuximab vedotin in combination with bendamustine for the treatment of pts with HL in first relapse (ClinicalTrials.gov #NCT01874054). Methods Pts received an outpatient IV infusion of 1.8 mg/kg brentuximab vedotin on Day 1 with 90 mg/m2 bendamustine on Days 1 and 2 of 3-week cycles for up to 6 cycles. Pts could undergo ASCT any time after Cycle (C) 2 and post-transplant resume treatment with brentuximab vedotin as monotherapy for up to16 total doses. Phase 1 was designed to determine the recommended dose of bendamustine in combination with brentuximab vedotin. During this phase, the dose of bendamustine was to be de-escalated if ≥4/10 pts experienced dose-limiting toxicity (DLT), defined as any C1 toxicity requiring a dose delay of ≥14 days. During phase 2, bendamustine was administered at the recommended dose in order to assess the CR rate of the combination. Response was assessed by the investigator per Cheson 2007. Results Forty-five pts (58% female) with a median age of 35 yrs (range, 19-79) have been enrolled. Fifty-eight percent of pts had relapsed disease and 42% of pts primary refractory disease after frontline therapy. A median of 13.1 mos (range, 3- 98) had elapsed since initial diagnosis. No DLTs were observed in the safety cohort, thus the recommended dose of bendamustine in combination with brentuximab vedotin was 90 mg/m2. Pts received a median of 2 cycles (range, 1-6) of the combination. The main toxicity observed with the combination was infusion-related reactions. The most common symptoms (≥10%) were dyspnea (13%), flushing (13%), and chills (11%). The majority of reactions occurred within 24 hours of C2 infusion and were considered related to both agents. Premedication with corticosteroids and antihistamines was instituted with a protocol amendment and appeared effective. Prior to the amendment, 36% (9/25 unique pts) of treated pts had reactions that were either serious adverse events (SAEs) (n=6), Grade 3 in severity (n=8), and/or led to treatment discontinuation (n=6). Following premedication implementation, 15% (3/20 unique pts) of treated pts had such events (0 SAEs, 1 treatment discontinuation, and 2 Grade 3 toxicities). The CR rate of the combination was 82% (28/34 pts evaluable for response) and the overall objective response rate (CR and partial remission) 94% (32/34 pts). The majority of CRs (24/28 pts) were achieved after 2 cycles of combination therapy. Stem cell mobilization and collection was considered adequate in all 24 pts who underwent the procedure. The median number of CD34+ cells collected was 4.3 x106 (range, 1.7- 16.0 x106) in a median of 2 apheresis sessions (range, 1-5). To date, 20 pts have undergone ASCT, the majority after C2 (12 pts) or C3 (6 pts), and 13 pts have resumed brentuximab vedotin as monotherapy. One patient with CR developed progressive disease 3 cycles post-transplant. The median duration of remission for pts who obtained a CR has not been reached (95% CI: 8.7,– [range, 0.03+-10.4+ months]). Conclusions The outpatient regimen of brentuximab vedotin 1.8 mg/kg on Day 1 in combination with bendamustine 90 mg/m2 on Days 1 and 2 of 3-week cycles has a manageable safety profile with premedication. The very high CR rate observed on combination treatment compares favorably with historical data. The durability of responses observed to date and the success of stem cell mobilization and collection suggest that the regimen may represent a promising approach for maximizing responses prior to ASCT in pts with HL who are either relapsed or are refractory after frontline therapy. Disclosures LaCasce: Seattle Genetics, Inc.: Research Funding. Off Label Use: Brentuximab vedotin is indicated in the US for treatment of patients with Hodgkin lymphoma after failure of autologous stem cell transplant or after failure of at least two prior multi-agent chemotherapy regimens in patients who are not ASCT candidates and for the treatment of patients with systemic anaplastic large cell lymphoma after failure of at least one prior multi-agent chemotherapy regimen. Bociek:Seattle Genetics, Inc.: Research Funding. Matous:Celgene: Consultancy, Speakers Bureau; Onyx: Speakers Bureau; Takeda Pharmaceuticals International Co.: Speakers Bureau; Seattle Genetics, Inc.: Research Funding, Speakers Bureau. Sawas:Seattle Genetics, Inc.: Research Funding. Caimi:Seattle Genetics, Inc.: Equity Ownership, Research Funding. Ansell:Seattle Genetics, Inc.: Research Funding. Islas-Ohlmayer:Seattle Genetics, Inc.: Research Funding. Cheung:Seattle Genetics, Inc.: Research Funding. Agura:Seattle Genetics, Inc.: Research Funding. Behler:Onyx Pharmaceuticals: Speakers Bureau; Seattle Genetics, Inc.: Research Funding. Crosswell:Seattle Genetics, Inc.: Consultancy, Equity Ownership, Research Funding, Travel expenses Other. Vose:Seattle Genetics, Inc.: Honoraria, Research Funding. Josephson:Seattle Genetics, Inc.: Employment, Equity Ownership. Advani:Janssen Pharmaceuticals: Research Funding; Genentech: Research Funding; Pharmacyclics: Research Funding; Celgene: Research Funding; Takeda International Pharmaceuticals Co.: Research Funding; Seattle Genetics, Inc.: Research Funding, Travel expenses Other.

Description: Distinct human dendritic cell (DC) subsets differentially control immunity. Thus, insights into their in vivo functions are important to understand the launching and modulation of immune responses. We show that nonobese diabetic/LtSz-scid/scid (NOD/SCID) mice engrafted with human CD34+ hematopoietic progenitors develop human myeloid and plasmacytoid DCs. The skin displays immature DCs expressing Langerin, while other tissues display interstitial DCs. Myeloid DCs from these mice induce proliferation of allogeneic CD4 T cells in vitro, and bone marrow human cells containing plasmacytoid DCs release interferon-α (IFN-α) upon influenza virus exposure. Injection of influenza virus into reconstituted mice triggers IFN-α release and maturation of mDCs. Thus, these mice may provide a model to study the pathophysiology of human DC subsets.

Description: Background: Venetoclax (VEN), a B-cell lymphoma 2 inhibitor, is an oral agent with demonstrated efficacy in patients (pts) with chronic lymphocytic leukemia (CLL). VEN treatment induces rapid tumor reduction, posing a risk for tumor lysis syndrome (TLS), particularly in pts with high tumor burden, and may require inpatient monitoring at the initiation of therapy. Agents such as obinutuzumab (G), ibrutinib, and bendamustine (B) have been used in clinical studies to debulk tumors prior to treatment with VEN. However, the benefits of these debulking regimens could not be established conclusively, as disease restaging was rarely performed. In the present study, disease restaging was performed every 2 cycles to evaluate the efficacy and safety of G, with or without B, as a debulking therapy in untreated pts with CLL, prior to VEN treatment in an outpatient community setting. Methods: This open-label, phase 3b trial (NCT03406156) enrolled adult pts with previously untreated CLL/small lymphocytic lymphoma (excluding those with 17p deletion) who had Eastern Cooperative Oncology Group performance status of ≤1 and medium (any lymph node [LN] 5 to