ALBERT

Description: Myelodysplastic syndrome (MDS) and chronic myelomonocytic leukaemia (CMML) are haematological disorders that develop in haematopoietic stem or progenitor cells (HSPCs) and are characterised by ineffective haematopoiesis. 5'-Azacitidine (AZA) is a DNA demethylating agent that is effective in treating MDS and CMML. However, response rates are less than 50% and the basis for poor response is currently unknown. A patient's potential to respond cannot be currently determined until after multiple cycles of AZA treatment and alternative treatment options for poor responders are limited. To address these fundamental questions, we enrolled patients on a compassionate access program prior to the listing of AZA on the pharmaceuticals benefit scheme in Australia. We have collected bone marrow from 18 patients (10 MDS, 8 CMML) at seven different stages of treatment, starting from before treatment until after six cycles of AZA treatment, and isolated high-purity CD34+ HSPCs at each stage. 10 of these patients (5 MDS and 5 CMML) responded completely to AZA while 8 did not achieve complete response. We performed next-generation sequencing (RNA-seq) of these HSPCs to identify the basis of poor response to AZA therapy. Analysis of the RNA-seq data from pre-treatment HSPCs has revealed a striking differential expression of 1148 genes between patients who were subsequently complete (CR) or non-complete responders (non-CR) to AZA therapy (Figure 1A). Using a Fluidigm nanofluidic system, we have validated the differential expression of a subset of these genes between CR and non-CR patients in two independent cohorts, totalling 67 patients, from the U.K. and Sweden. We have additionally confirmed that our gene signature does not simply segregate patients based on disease severity or poor overall survival, but rather uniquely prognosticates best AZA response. Pathway analyses of the differentially expressed genes indicates that the HSPCs of non-CR patients have decreased cell cycle progression and DNA damage pathways, while concomitantly possessing increased signalling through integrin and mTOR/AKT pathways. Using computational methods, we have determined that the expression of 15 genes (within the 1148 gene set) is sufficient to separate CRs from non-CRs across independent cohorts (Figure 1B). We have also developed a predictive AZA response algorithm that utilises the expression of these genes to identify potential complete and non-complete responders to AZA with high specificity and sensitivity (Figure 1C). Furthermore, we have identified statistically significant correlations between recurrent DNA mutations in MDS and our prognostic gene signature (SF3B1 & TET2 with CR, STAG2 and NUP98 with non-CR, p

Description: Background/Objective: Breakthrough hemolysis (BTH) is the return of hemolytic disease activity during treatment with complement C5 inhibitors for paroxysmal nocturnal hemoglobinuria (PNH). BTH may be associated with inadequate C5 inhibition or complement activating conditions (eg, infection). Despite reports that up to 19% of patients (pts) receiving eculizumab may experience BTH, there is no commonly accepted definition of BTH. The definition of BTH was derived from literature review and expert consensus. BTH was defined as ≥1 new or worsening symptom/sign of intravascular hemolysis (fatigue, hemoglobinuria, abdominal pain, dyspnea, anemia [hemoglobin

Description: Refractory aplastic anemia (AA) is defined as a lack of response to first-line immunosuppressive therapy (IST) with antithymocyte globulin and cyclosporin and is manifested as persistence of severe cytopenias at 6 months after IST. Although supportive care is critical for AA patients, it is of paramount importance for refractory disease in view of the longer duration of pancytopenia and susceptibility to life-threatening infections due to IST. Improvements in supportive care have largely contributed to better outcome over the past 2 decades, with 5-year overall survival reaching 57% during 2002 to 2008 for patients with AA unresponsive to initial IST. Exclusion of hypocellular myelodysplastic syndrome and constitutional BM failure masquerading as apparent idiopathic AA should be done in conjunction with centers of excellence. Hematopoietic stem cell transplantation is indicated if refractory AA patients are fit and have a suitably matched donor, either a sibling (〉40-50 years) or unrelated donor. Patients lacking a fully matched donor should be considered for a second course of antithymocyte globulin plus cyclosporin, although response in the refractory setting is only ∼30% to 35%. Response may also occur with alemtuzumab or the thrombopoietin mimetic eltrombopag in refractory AA. The emerging data for alternate donor (cord or haploidentical) transplantation in AA has provided additional therapeutic choices to consider in refractory disease.

Description: Key Points There is 100% concordance in the cytogenetic and mutation profile between PB and BM in myelodysplastic syndrome.

Description: Introduction: Anemia occurs in 80-90% of patients with myelodysplastic syndromes (MDS), nearly half of whom are red blood cell (RBC) transfusion dependent (TD) at diagnosis. The presence of anemia, transfusion dependency, and the resulting complications exacerbate the burden of MDS. Patients with lower-risk MDS have longer overall survival (OS) than patients with higher-risk MDS; however, TD status and higher transfusion load significantly reduce OS. Treatment of lower-risk TD MDS aims to achieve RBC transfusion independence (TI), hematologic improvements and alterations in erythroid response according to IWG 2006 criteria, and improved health-related quality of life (HRQoL). To evaluate these points, we performed a systematic literature review (SLR) to assess the burden experienced by adult patients with RBC TD anemia in lower-risk MDS. Methods: Embase®, MEDLINE®, and the Cochrane Library were systematically searched from inception to March 2019 to identify observational studies reporting on the HRQoL, clinical, and epidemiological burden as well as treatment patterns for adult patients with lower-risk MDS who were RBC TD. Conference proceedings from the last 2 years were searched to identify recent data not yet published as a full text article. Only English language articles and conference abstracts were included. References were screened at the title/abstract and full-text levels by 2 independent reviewers, with methodology following Cochrane guidelines. Results: Database searches yielded 1,175 records. After removing duplicates, 837 abstracts were reviewed, with 152 publications progressing to full-text review. Ten studies met the eligibility criteria. Two additional records were identified from hand searching (Figure). Many studies reported on mixed MDS patient populations, where only a subset were lower-risk and TD, limiting the amount of data available. Nine studies were from the USA or EU5 (France Germany, Italy, Spain, United Kingdom) as well as 1 international study encompassing Europe, the USA, and Australia. The majority of studies defined risk status using the International Prognostic Scoring System (IPSS) risk score, with only 1 study reporting both IPSS and Revised-IPSS (IPSS-R) score. Where reported, patients were mostly older (mean age 〉 70 years). Burden data were sparse, with few outcomes reported across multiple studies (Table). One study from Italy (mean age 72 years) reporting EuroQoL 5-dimension Visual Analogue Scale data indicated that patients with TD MDS had worse scores (53.0) compared with patients aged 65-74 years in the general Italian population (67.8). Clinical data indicated a variable OS rate across studies conducted in Spain and France, as well as in the 1 international study, with a 2-year OS rate of 73.2% and 4-year OS rates ranging from 27.6% to 73%. The data consistently reported that patients with TD MDS had shorter OS than patients with TI MDS. Differences in timepoints for assessment, types of treatments, and RBC transfusion load increased the variation in OS data. TI was defined as a transfusion-free period of ≥ 56 days, or 8 weeks, in most studies. Median time to reach TI (when reported) ranged from 32-97 weeks, although the prolonged length of time it took to reach TI and the proportion of patients achieving TI indicated an extensive time on treatment. Similar conclusions were drawn in 3 studies that compared OS in patients who became TI with those who remained TD. Epidemiology data were limited to mortality data, and no data were available on morbidity, incidence, or prevalence of disease. Mortality data provided an incomplete picture; deaths were reported as overall mortality or non-leukemic deaths, obscuring mortality rates specifically associated with lower-risk TD MDS. Treatment patterns were reported in 3 studies; erythropoiesis-stimulating agents and hypomethylating agents were the most common treatments reported. Conclusions: Data on the burden of illness in patients with lower-risk MDS with TD anemia were limited and reported inconsistently across studies. Despite this heterogeneity, HRQoL outcomes had a trend toward worse scores in patients with TD MDS than in the general population. OS rate at 2 and 4 years indicated worse prognosis in patients with TD MDS compared with the general population. To better understand the burden of illness, further robust observational studies are needed to close the evidence gaps in this population. Disclosures Deshpande: Evidera: Employment; Celgene Corporation: Consultancy. Turner:Evidera: Employment; Celgene Corporation: Consultancy. Byrnes:Evidera: Employment. Pelligra:Celgene Corporation: Research Funding; Evidera: Employment. Rines-MacEachern:Evidera: Employment. Chitnis:Celgene Corporation: Consultancy; Evidera: Employment. Kulasekararaj:Celgene Corporation: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Alexion: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Achilleon: Consultancy; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Ra Pharma: Honoraria, Membership on an entity's Board of Directors or advisory committees; Akari Therapeutics: Consultancy. Tang:Celgene Corporation: Employment, Equity Ownership. Morison:Celgene Corporation: Employment. Oliva:Apellis: Consultancy; Celgene Corporation: Consultancy, Honoraria, Speakers Bureau; Novartis: Consultancy, Speakers Bureau.

Description: Introduction Ravulizumab, an innovative complement C5 inhibitor given every 8 weeks (q8w), was recently demonstrated in a large phase 3 study of patients (pts) with paroxysmal nocturnal hemoglobinuria (PNH) and naïve to complement inhibitor therapy to be non-inferior to eculizumab given every 2 weeks (q2w) across all endpoints that measured different aspects of PNH disease (transfusion avoidance [TA], lactate dehydrogenase normalization [LDH-N], percent LDH reduction, breakthrough hemolysis [BTH], Functional Assessment of Chronic Illness Therapy [FACIT]-Fatigue, and hemoglobin stabilization [HGB-S]) (Lee JW et al. EHA Learning Center, Jun 17, 2018; LB2603). PNH pts currently receiving eculizumab may experience treatment burden associated with the q2w dosing regimen. With the development of ravulizumab, PNH pts on prior eculizumab therapy can potentially switch to ravulizumab without interruption of treatment. The primary objective of this study was to assess the noninferiority of ravulizumab compared to eculizumab in adult PNH pts who were clinically stable after having been treated with eculizumab for at least 6 months. Methods In this phase 3, open-label, multicenter study (NCT03056040), adult pts with a documented diagnosis of PNH who were treated with labelled-dose eculizumab for 〉6 months having LDH levels ≤1.5 times the upper limit of normal at screening were randomly assigned 1:1 to continue eculizumab or switch to ravulizumab. Pts randomized to ravulizumab received weight-based loading [day 1]/maintenance doses [day 15 and q8w thereafter]: ≥40 to

Description: The genetic diagnosis of inherited anaemias is an important aspect of the diagnostic pathway for patients with haematological disorders, allowing discrimination between conditions of overlapping phenotypes therefore enabling more effective clinical treatment. Next Generation sequencing platforms are now in widespread use in diagnostic settings and are facilitating more rapid, accurate and cost-effective molecular diagnosis. The Red Cell Gene Panel developed by the Viapath Molecular Pathology laboratory based at King's College Hospital, London has harnessed this technology with the aim of identifying genetic diagnoses of rare inherited causes of anaemia. Although originally setup to diagnose inherited red cell disorders, clinical demand has led to the inclusion of inherited bone marrow failure syndromes and other related conditions such that the panel now consists of 194 genes, divided into 16 subpanels (see table 1). Here we present the data from the first 1000 diagnostic cases reported under the following referral groups: 462 cases of unexplained anaemia (including haemolytic anaemia, sideroblastic anaemia, congenital dyserythropoietic anaemia, Diamond-Blackfan Anaemia), 232 cases of inherited bone marrow failure syndromes (including thrombocytopenia and neutropenia), 163 cases of congenital erythrocytosis and 143 other cases (including but not limited to iron regulation, haemophagocytic lymphohistiocytosis (HLH) and Criggler-Najjar ). Of these 1000 cases, we have achieved an overall diagnostic yield of approximately 25%. A diagnosed case is defined here as one in which a clear pathogenic or likely pathogenic variant that explains the phenotype has been detected. The unexplained anaemia cases have achieved the highest percentage of cases diagnosed with 47% diagnostic yield and data will be presented outlining the gene-by-gene breakdown of diagnoses made. Our bespoke bioinformatics pipeline has also allowed the detection of novel disease-causing structural variants in 20 cases, contributing 2% of our diagnostic yield. These are detected using three different methods; read-depth analysis, split-read mapping and discordant insert-size analysis. All reported structural variants have been confirmed with a second method, either breakpoint mapping or dosage-sensitive PCR. A significant proportion of cases (28%) have been reported with variants of uncertain clinical significance, highlighting the need for family studies and functional characterisation to be able to accurately ascertain the significance of these variants. Future developments of the service include functional characterisation of membrane disorders using next generation ektacytometry and preliminary data from this work will be presented here. Disclosures Kulasekararaj: Alexion Pharmaceuticals, Inc.: Consultancy, Honoraria, Other: Travel Support . Pagliuca:Gentium: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Jazz Pharmaceuticals: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Description: Abstract 787 Introduction: The hypomethylating agent 5-azacytidine (5-azaC) leads to improved survival compared to conventional care regimens in patients with intermediate-2 and high-risk MDS and Acute Myeloid Leukaemia (AML) with less than 30% blasts. The precise mode of action of 5-azaC is uncertain, however a combination of cytotoxicity and demethylation is partly responsible for its anti-leukemic activity. In addition, 5-azaC has a profound effect on immune function and inhibits T cell proliferation and activation, blocking cell cycle in the G0 to G1 phase and decreases the production of pro-inflammatory cytokines, suggesting a possible in vivo and in vitro immunomodulating role that may contribute to its anti-leukemic activity. The aim of this study was to investigate the effects of 5-azaC on different subsets of CD4+ T cells, including regulatory T cells (Tregs) and T helpers (Th1, Th2, and Th17). Patients and methods: Seventy intermediate-2/high risk MDS patients and 10 healthy age matched donors (HDs) were studied. CD4+ and CD8+ T cells subsets (percentages and absolute numbers) were investigated by flow cytometry. All patients have received 5-azaC and peripheral blood samples were collected at diagnosis and after 1, 3, 6, 9 and 12 month from initial treatment. On average 3 samples were collected per patient. In vitro study: 5-azaC was added to pre-stimulated PBMCs from 4 HDs and 3 high-risk MDS patients to facilitate the drug incorporation. After 48 hours of initial stimulation, 5-azaC was added every 24 h up to 96 h on two different concentrations (1 μM and 2 μM). For each timepoint (t0, t+24, t+48, t+72, t+96) cells were stained with CD3, CD4, CD25, CD127 and Foxp3 for Tregs and with CD3, CD4, IFN-γ, TNF-α, IL-4, IL-17 for T helpers after an additional 4 hours stimulation with PMA/Ionomycin. Results: In vivo results: Numbers and percentages of Tregs were significantly higher in patients' peripheral blood prior to treatment compared to HDs (0.7% v 0.08%, p

Description: INTRODUCTION Ravulizumab, an innovative long-acting C5 complement inhibitor, was recently approved in the United States, Europe, and Japan for the treatment of paroxysmal nocturnal hemoglobinuria (PNH). In the largest phase 3 study (ALXN1210-PNH-302; NCT03056040) in eculizumab-experienced PNH patients (pts), ravulizumab (q8w) was shown to be noninferior to eculizumab (q2w) after 26 wks for all primary and key secondary endpoints. At the end of the 26-wk treatment period, all pts had the option to receive weight-based dosing of ravulizumab in an extension for up to 2 y. We report on the efficacy and safety of ravulizumab through 52 wks of treatment. METHODS This was an extension of the open-label, phase 3, multicenter study described above. Adult PNH pts who were stable on eculizumab for ≥6 mo and with lactate dehydrogenase (LDH) of ≤1.5xULN at screening were randomly assigned 1:1 to switch to ravulizumab or continue receiving eculizumab for 26 wks. After 26 wks, pts in the ravulizumab arm continued ravulizumab maintenance therapy (R-R arm), and pts in the eculizumab arm were switched to ravulizumab (E-R arm). For the 52-wk data, the primary efficacy endpoint was percent change in LDH from baseline (BL), and key secondary endpoints included the proportion of pts with breakthrough hemolysis (BTH), transfusion avoidance, improvement in FACIT-Fatigue total score, and stabilized hemoglobin (HGB-S) levels. Additional endpoints included change in plasma free C5 levels from BL and safety evaluations. RESULTS Of the 192 pts who received ravulizumab during the study, 191 entered the extension period (R-R arm: n=96; E-R arm: n=95). Pts in both groups showed a durable response for percentage change in LDH up to 52 wks, similar to what was observed during the first 26 wks (Figure A). At 52 wks, pts in the R-R arm had an 8.8% increase in LDH from baseline (standard deviation [SD], 29%), while pts in the E-R arm had 5.8% (SD, 27%) change in LDH from baseline. Mean LDH levels in both groups were maintained at 1.0xULN (